CORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 1048-iii

House of COMMONS

Oral EVIDENCE

TAKEN BEFORE the

Health Committee

PUBLIC HEALTH

Tuesday 21 June 2011

Professor Peter Goldblatt, Dr Jessica Allen and Professor Stephen Morris

Dr David Halpern, Professor Sir Ian Gilmore, Mark Baird and Chris Arnold

Evidence heard in Public Questions 176 - 288

USE OF THE TRANSCRIPT

1.	This is a corrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
2.	The transcript is an approved formal record of these proceedings. It will be printed in due course.

Oral Evidence

Taken before the Health Committee

on Tuesday 21 June 2011

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Yvonne Fovargue

Grahame M. Morris

Mr Virendra Sharma

Chris Skidmore

David Tredinnick

Dr Sarah Wollaston

________________

Examination of Witnesses

Witnesses: Professor Peter Goldblatt, Senior Research Fellow, Marmot Review Team, Dr Jessica Allen, Project Director, Marmot Review Team, and Professor Stephen Morris, Professor of Health Economics, University College London, gave evidence.

Q176 Chair: Good morning. Thank you for joining us this morning. Could I ask you to begin this session by briefly introducing yourselves?

Dr Allen: I am Dr Jessica Allen. I was the Project Director for the Marmot Review.

Professor Goldblatt: I am Peter Goldblatt. I am a member of the Marmot Review Team.

Professor Morris: Hello. My name is Steve Morris. I am a health economist and I am interested in resource allocation in health care.

Q177 Chair: Thank you. We would like to begin by focusing the questions, if we may, on the Marmot Review and its implications for policy. Perhaps I can begin by saying that, for the members of the Committee, broadly speaking, it is common ground that there are close linkages between social background and health outcome. That aspect of the Marmot Review findings we can, therefore, probably take as read.

What we are interested in is the conclusions that that leads to in terms of policy and the way the Government has reacted to the Marmot Review findings and recommendations from a policy point of view. Could I begin by asking Professor Goldblatt to open the proceedings by summarising where you feel the Marmot Review led us in terms of key policy recommendations and how you react to the Government’s response to the Marmot Review so far?

Professor Goldblatt: I will begin and share the response with my colleague. Broadly, we came up with six recommendations around the life course. The first of them was on early-years development and the importance of that. The second was on education and training in life, to give people control over their lives. The third was on work, the workplace and employment. We then had recommendations on the environment in which people live and ill-health prevention and, finally, a recommendation on a minimum income for healthy living.

So we had six broad areas of recommendation. There is more detail to each of those. The broad intention is to give people and communities in which they live control over their lives, this being central to good health and good well-being, recognising that many of these, as you said, are all related to the social determinants of health-to the circumstances in which people are born, live and work.

What we concluded in general terms is that to address the six areas, you need a whole-of-Government approach. The NHS is important, but it cannot deliver these on its own. The Government has to work across all parts of Government and a lot of these have to be delivered at local level. It is not purely about central Government policy, though that, of course, is key; it is also about how local agencies work together in partnership to deliver these objectives.

Q178 Chair: There is probably nothing you have said, I do not think, that any member of the Committee would disagree with, although it is not my job to speak for them. I guess the added value I am looking for, certainly, in the health policy arena is something that takes the argument beyond a proposition that stands on its own, independent of its linkage to health. For example, improving life chances and control over one’s own life is something that, it seems to me, is a social policy objective you can justify in its own terms quite independently of the effect on health. The question is: what, additionally, the public health argument adds to a proposition which is a free-standing proposition that most of us would sign up to, independent of the effect on health?

Dr Allen: Where policies are aligned in their objectives-the example that you gave is a good one-and if you add in the importance to health of that particular policy objective, I think it should be given additional priority as a result of that. As a free-standing policy objective it is a very good one and one you would all, maybe, sign up to, but, when you add in the importance to those policies to health, which is not necessarily recognised in the design and implementation of policy, it changes the shape of the policy a bit. We argue that it should mean that those policies have greater priority and, therefore, resources and effort, going towards achieving them.

Professor Goldblatt: What I would add to that is around the evidence base. The link between those policies and health- in what particular ways do you need to deliver those policies I outlined in order to achieve the maximum health benefit. That is, through the life course, identifying the ways in which early child development affects health. What matters in terms of an under-five, what matters in the womb, what matters to an infant as to how they will develop and then have a healthy life, as a consequence. All this is within the evidence base and requires particular actions which, as you say, turn out to be very similar to what you would say is needed to ensure that we had a vibrant economy and that we reduced crime in the community, etcetera. They are fairly similar, but there are specifics which lead to greater health benefits.

Q179 Chair: I understand the principle. Could you give the Committee a couple of examples of specifics where the health argument adds value to those general propositions?

Dr Allen: In the report we looked particularly at climate change mitigation efforts because it seemed that there were some very clear similarities in actions taken to reduce the impact of climate change and things which, say, encourage active travel, better quality of green spaces and so on. That was one area we prioritised. Earlier, as I think Peter said, there is some very clear evidence on the linkages and benefits of those policies being aligned. That is another area where we would like to see this very explicitly.

Can I make one additional point about the gradient, which does have implications for policy design? The links between social and economic status and health are on a very clear gradient; we are not just dealing with the gap between the top and bottom, which I think a lot of policy has been designed around previously. We argued that, as a result of all the evidence which points to this social class gradient in health, policy should be designed in a way which is both universal, to tackle and lift the gradient, and also proportionate to the depth of the problem, so we see more action towards the bottom end of the social class gradient than towards the top, but necessarily universal as well.

Q180 Chair: Proportionate universalism is a new concept for which we are indebted to Sir Michael and his team.

Dr Allen: Not the best term, but yes.

Q181 Chair: The second part of my question was about the Government’s response. What are the headlines of your reaction to the Government’s response?

Professor Goldblatt: We welcomed the emphasis - in the White Paper - on our recommendations, on taking a life course approach and on accepting the principle of proportionate universalism. However, we would have preferred that they accepted all six of our recommendations and we do see a minimum income for healthy living as being an important recommendation. The early years recommendation was the most important but we do also see it as important that people have sufficient income-including benefits (i.e. net income after benefits and taxation)-to participate in society and to be able to buy the necessities to have a healthy life for themselves and their children.

When we compare the poverty levels overall to the amount that particular groups in society have in the way of income-the evidence which we presented in the report showed, for example, that lone parent families were particularly badly off in terms of a minimum income for healthy living. Other groups were less badly off compared to the poverty level. The minimum income is a shift in policy. It is focusing on particular circumstances of individuals, and participation in society is key to having control over your life. That is what we see as missing in the current structure of policy. That is a very specific area where we would have liked to see more done.

The other area where we would have liked to see more emphasis is on local delivery, on partnership working locally, on accepting and putting forward proposals on how to promote a whole-of-Government approach. That is, as I said, at local level as much as at central level. It is not simply about Government Departments being joined up; it is about ensuring that local partnerships are more vibrant than they are at the moment. Again, moving public health into local government is, in principle, welcomed. Of course, the devil is in the detail as to how that is implemented.

Chair: We shall be coming on to that.

Dr Allen: I have a couple of points. As Peter mentioned earlier, we need to look at all policy areas across Government to really understand health inequalities. We do have concerns that some of the wider Government policies and the financial situation generally will impact on health inequalities down the line. We have some worries about the cuts, particularly to local government budgets and how that will impact on the services which are being delivered on the people who are most vulnerable and increasing numbers of people who are being made vulnerable as a result of some of the financial situations. Of course, this is not unique to England; it is happening across Europe, and Governments across Europe are struggling with a similar problem.

There is one additional point. We have seen a very good response locally. The national Government response we have talked about but, locally, the response to the Marmot Review has been very encouraging. A large number of local authorities, PCTs and, increasingly, GP consortia, are taking on the agenda and developing their own plans and strategies, which is absolutely central to what we said in the Review and, I think, central to a lot of the Government’s agenda as well. That is an encouraging sign which we are very pleased about and we are working with some of those local authorities to embed some of the high-level recommendations which we made in this to get them implemented locally. That has been a very encouraging development.

Q182 Dr Wollaston: Can I follow on from that and ask you for some specific examples of where you think that has been particularly successful?

Dr Allen: Yes. We have been working quite closely, in London, both with the Mayor’s Office-they have a very strong health inequalities strategy, which we are helping embed within all the local authorities in London-and we have also been working with Ealing local authority and their new Health and Well-being Board, to try and get a good agenda for them to kick off with, as they begin to develop their plans. We have been looking at parenting and early-years strategy with them and they will take that to the wider local authorities there.

The north-west of England has done some excellent work, as a region, in trying to embed our recommendations and there are examples, across the country, of local authorities and PCTs who have their health inequalities and public health strategies based on the six recommendations we came up with. There is a different take on them all across England but, basically, there is a general acceptance in many areas that this is the way to tackle health inequalities.

Q183 Dr Wollaston: They are using your report as a framework.

Dr Allen: Yes.

Dr Wollaston: Thank you.

Q184 Chris Skidmore: Can I come in on that point of the general acceptance? It does seem, on this principle of proportionate universalism, that it has been universally accepted. I wondered if there was any criticism of that principle within the health community or within the health academics. From my own point of view, looking at the nature of intervention, and, obviously, different communities will respond differently to interventions-I know, Professor Goldblatt, you mentioned about giving communities control over their own lives.

I may be wrong, but is there not the risk that one community will take greater control over its own life-possibly an affluent community-whereas a more disadvantaged community will not? The more affluent local area may respond better to intervention than a more deprived community and, therefore, you might see a widening gap taking place. Has there been any criticism of this idea of proportionate universalism? Elsewhere, internationally-say in the States, for instance-what you see with ideas with ObamaCare and, say, Jeff Brenner of the Camden Coalition, is a completely different idea of outreach interventionism, where you are focusing on the bottom 1% and going in really hard to tackle those communities. I just wondered, by having a universal approach, is there not a risk that we create this widening gap?

Professor Goldblatt: Yes, there is a criticism based on the traditional way of addressing inequalities which has been to target the most disadvantaged communities and see an inequality strategy as separate from the bulk of NHS universal care. What we are looking to do is to blend those two so that the effort and resource that goes in is proportionate to need. I think you are quite right that it is far easier to achieve health gain in the most affluent areas. That is where the concept of proportionate universalism applies across local areas as well as within local areas. Earlier this year, with the London Health Observatory, we published indicators, both between and within area, related to our preferred target indicators to show those areas which had an overall high level of ill-health and deprivation and those areas, which are not the same, which have a large gradient within the area. Some of the most affluent areas in the country, like Westminster, have a large gradient.

Q185 Chris Skidmore: With a gradient-obviously, with any gradient-you have to have the Y axis and the X axis. What is the information you place on those two axes? One of the problems I find is we do not have the patient information, sometimes, to be able to locate where the areas of need are. Would you be able to go into some of the data and outcomes?

Professor Goldblatt: Yes. Broadly, until we do have that information at individual level, we have largely used-and we used in Fig. 1 of our report-proxy information on the level of income deprivation of neighbourhoods. That is what we have largely used as the basis for assessing the gradient within an area. But when you look, say, at Westminster, it is fairly self-evident that different parts of the borough have very different levels of affluence.

Q186 Chris Skidmore: Is it a lower super output area type of material?

Professor Goldblatt: Yes. Some of them are based on lower super output areas and some on middle level output areas, depending on the availability of the information.

Q187 David Tredinnick: Westminster is the absolutely extreme case, I would suggest to you, where, north of the railway line, you have north Paddington-

Professor Goldblatt: Exactly.

David Tredinnick: -which is deck access housing with all kinds of social issues. You have a whole plethora of issues to deal with up there and, at this end, you have the highest longevity in the country.

Professor Goldblatt: Absolutely. That is why I was using it to illustrate-close to home, if you like-that you can use proxy information provided the information is at a low enough geographic level. If you purely use the information for Westminster as a whole, you lose that texture. If you have neighbourhood information, then it is very clear that neighbourhoods vary considerably.

Q188 Chair: It is quite an interesting philosophical issue, isn’t it? You have said, very directly, that interventions are more effective in affluent areas than less affluent areas. That leads to the conclusion that you want proportionate universalism, which I understand, but, in terms of an intervention that generates a good for a citizen, then the intervention is likely to be more effective if the citizen is affluent.

Professor Goldblatt: Absolutely, which is why we have focused on the life course in saying that you need to get to that point where, if you are talking about adults, every individual has a greater life chance to be able to take advantage of those interventions and why we say that interventions need to begin in the early years. It is only by doing that that, in future years, interventions will become easier in the poorer areas. It is exactly that point.

Q189 Chris Skidmore: Coming back to the life course-you touched on it as well-the NHS cannot do everything. It is quite clear, just looking at the stages you have set out, we have the issue of childhood and early intervention and then, obviously, with social care, there is the issue with the NHS taking over those people who, clearly, in the last stages of their life often have multiple illnesses and chronic conditions. Take, for instance, the one issue, the case where the NHS often doesn’t see people for a long time, is in the work and family building stage, age 19 to 64, that is obviously where we have a problem because the lack of diagnostic testing means that people only turn up at A&E hospitals once everything has gone catastrophically wrong. What type of interventions can you realistically make without the NHS in that period that is often a dark age period for the NHS?

Dr Allen: One of the clearest evidence bases is the relationship between employment and health: first of all, that employment is good for health and long-term unemployment is very bad for health. Across all the social classes you see a drop. Even for the wealthiest, most qualified people you see a drop in their health as a result of unemployment. That is the first point that is very well known.

The second point is that it is not just any work which is good for health. It is good quality work. There are certain types of work where the control and reward balance and the effort and reward balance is more equal and has good impacts on physical and mental health-and mental health is very important in that. You see the gradient, in terms of quality of work, by social class as well. There are very easy and effective things which can be done to improve quality of work which have a big impact on quality of life and on physical and mental health. We made quite a lot of recommendations in the report about improving the quality of work which is really for the private sector, for large employers, for the NHS to implement. I think you would see some big improvements across the social gradient if some of those efforts to improve the quality of work were implemented.

Q190 David Tredinnick: This is a question for Dr Allen and Professor Goldblatt. The Government has emphasised the need to build individuals’ confidence and self-esteem as a central part of getting them to choose healthy lifestyles. How credible do you think that approach is? Is it sufficient to tackle health inequalities generally?

Professor Goldblatt: It is necessary, but not sufficient. The important thing is that if you are dealing with a number of adults of working age and they have lost out in childhood and they have lost out in education, they will not have that ability to control their lives which is necessary to take advantage of lifestyle and behaviour initiatives. That is why I said it is much more difficult to achieve improvements from that starting point. Taking the long view, I reiterate that you need to start with early years, with education, and education around the whole of the social and emotional life of the child. It is about whole-school initiatives. You need to be taking initiatives right across the life course to get to that point. That is not to say, of course, that you cannot take initiatives to build up esteem among adults, but it is going to be more expensive, in essence, to do that.

Q191 David Tredinnick: What about the ladder of interventions that is mentioned in the White Paper? How do you feel about that? How adequate is nudging, generally, as a way of addressing health inequalities?

Dr Allen: It is very clear that the most successful interventions which have had the greatest impact have come through quite strong regulation-the bans on smoking in public places, wearing seat belts and so on. Those quite strongly regulated public health interventions have been the most impactful. As Peter just set out, building individual confidence through nudging or through various other means through education is absolutely essential to improving health, but it is not sufficient. You need a whole range of interventions including, we argue, fairly strong regulation, for example, of the food and drinks industry which is something we have argued for in order to effect these changes. Nudging will not be enough, even if it is successful-and there is variable evidence about whether it can be.

Q192 David Tredinnick: Just on that point, and looking at the drinks industry generally, to take the case of obesity, which is part of a strategy, there is a lot of emphasis now on diet drinks, diet colas. I listened to a professor in the other House-not in the Chamber, obviously, but in a Committee room-who was suggesting that, whereas with diet colas, for example, the calorie intake is suppressed because sugar is taken out, the sugar substitutes actually stimulate appetite. Although you drink a less fattening cola and you get all the points, an hour later you are ravenously hungry. Would you like to comment on that?

Dr Allen: I am not aware of that evidence. Are you?

Professor Goldblatt: No, but I think, in terms of the more general issue about obesity, it is not simply about making choices over a single drink. It is about the balance of healthy food that you eat and your ability to have sufficient control over your life, as we have said before, to make those healthy decisions.

Q193 David Tredinnick: On that specific point, with television advertising-social marketing-there is a massive emphasis on advertising food to children now. The food industry actually makes money by getting people to eat more food. There is a lot of subliminal advertising, a lot of fast frames coming up. Do you think we should be regulating that? How important is that, in your view, please?

Dr Allen: I think it is important but regulation should go further than just the messages which are put out. Those are very important, but there are plenty of other things. For example, there is what is called an obesogenic environment, which is about the amount of activity people can do playing outside. Much wider issues are to do with the importance of early years, good nutrition, proper parenting and so on. It is a very wide social programme which is needed to tackle obesity.

There is far more that the food and drinks industry can do-food labelling would be one example, promoting healthy foods, reducing portion size and so on-but they are almost at the end of a spectrum of interventions. They are perhaps the most obvious but they come at the end of a long chain of interventions which start with the wider social environment and with education in the early years. Our focus has been much more on the upstream interventions than on the downstream interventions, which are important, and we would like to see more regulation and so on within the food and drinks industry and the supermarkets having a different approach to some of these issues, perhaps, but, also, we would like to see far more upstream.

Q194 David Tredinnick: Can you take the jargon out? "Upstream" and "downstream"? I used to row a bit, but I don’t recognise those in the health context. What do you mean by that?

Dr Allen: The downstream interventions-sorry about the jargon-are interventions which relate directly to individuals and are about changing behaviour at the point of purchase. Upstream interventions are much more about the wider social context. They are the big social policy movements or changes-for example, in education in early years-but you are further away from an individual perspective.

Q195 Chair: Individual regulation has a role to play but it is not, by itself, enough. Certainly, you minimise the effectiveness of it if you do not set a more receptive social and individual context. I understand that. That is a fair way of putting it.

Dr Allen: Yes.

Q196 Dr Wollaston: Presumably, you can reduce the obesogenic environment by not having things like crisps and sweets right next to a point-of-sale.

Dr Allen: Yes.

Q197 Dr Sarah Wollaston: Presumably, that will be more effective than just educating people that they should not eat them, or do you think they are both equally effective?

Dr Allen: Yes. Two points, though. That would be effective, in a small way, but people would still buy crisps and sweets. We know that, but, yes, having them inaccessible there would be a useful thing to do. The point about education is that it is not just educating people to eat healthier; it is about having a better education system. These are big social things which would have an impact on health, and there is plenty of evidence to show that. We know that people with higher qualifications have better health, live longer and have less illnesses, partly because they have more control over their own lives, because they have aspirations to be healthy and so on. You are really talking about interventions which do not seem to have anything to do with where the crisps are located in the shop, but do.

Q198 Chair: They might not be in the sweet shop in the first place.

Dr Allen: Yes, quite possibly.

Q199 Mr Sharma: You suggested that when the people miss out in their childhood, in their education, it is also very important that their adult health will be looked after. You said that this can be handled, but it will be very expensive.

Professor Goldblatt: Yes.

Q200 Mr Sharma: But we cannot ignore it?

Professor Goldblatt: No.

Q201 Mr Sharma: Can you make some recommendations on that or have you done so?

Professor Goldblatt: Yes, we have made recommendations on that. As you say, the main recommendation, in essence, is about adopting a proportionate universalist approach because you recognise, if you are going to change the health and lifestyles and behaviour of the most disadvantaged people, that that requires proportionately more effort to get the same improvements-and those are specifically around ill-health prevention activities and improving the workplace.

As Jessica said, in terms of the workplace it is about the kinds of recommendations that Dame Carol Black recommended in her report: about an improved occupational health service and about getting people into good quality work. It is about, as we have just been discussing, reducing the obesogenic environment, which is both about food regulation and the availability of fast food outlets as well as green spaces in which people can exercise more-again, an observation that, in poorer areas, there are less safe, accessible green spaces than in the leafy suburbs. It is also about improving active travel-again, the more affluent are adopting healthier ways of travelling because of all the advantages they have, whereas the most disadvantaged are still not getting the amount of exercise they need. It is both exercise and food that are key to reducing the obesogenic environment.

There are also recommendations we made about the availability of alcohol which, as we have seen in other countries in Europe, has become a predominant factor in early mortality. It is becoming more and more important in this country. There has been a steady rise in early-onset cirrhosis as an indicator, but excess alcohol use has a range of other health-threatening conditions. Again, there are a variety of things you can do-just going back to the point-persuading someone who has a life which they are less able to control in terms of their daily life who is then less able to adopt all of these healthy behaviours.

Mr Sharma: Thank you.

Chair: Professor Morris has sat extremely patiently. Chris will be going on to your specific line of questioning.

Q202 Chris Skidmore: We are getting on to the line of questions on which I am sure your expertise will be valued, and that is the budget for public health. Obviously, the Government have come out in their White Paper to say that the estimated budget is going to be something just over £4 billion which seems to chime nicely with the table in the Marmot Review for the ill-health prevention expenditure-that correlates in with that.

But I have seen, from your written evidence, that you both suggest that is not enough and that you would ideally like to see 7% of the NHS budget spent on public health. I was wondering if you could give a justification of why that should be the case-how you came to that rough percentage figure and how you see the public health budget expanding in the future. One of the issues with public health is that there are so many things you can claim is a public health responsibility. We will come on to that in a later question on ring fencing. Why do you think we should probably need to double the public health budget by 2015?

Professor Goldblatt: We came at it from three different angles. The first was, simply, when you look at that breakdown in our report, which came from a Health England report and from the OECD split on how you define public health expenditure, you see that much of public health expenditure is on vaccination and immunisation and on the Health Protection Agency, which, of course, are important things-they need to take place, it is important to overall health-but it is about prevention. It is not about earlier interventions in public health to improve the overall health of individuals. It is to stop particular diseases and problems. The first element was that you need a certain amount for that kind of intervention we have been talking about. At the moment, very little of the public health budget is spent on that. Some people have estimated it is something like 0.5% being spent on that element. Our first take on that was you need at least an equal amount, and that is why we suggested a doubling.

The second take was looking in the Health England report which showed that we spend about one third as much, in terms of the proportion of health expenditure, on public health as they do, say, in Canada, and less than the OECD average. Therefore, doubling seemed a modest increase.

The third element was around the specifics of what that budget should be spent on, which is, I think, what you were talking about. The first is on overall health improvement-the universal part of it-which we were discussing earlier. The second is about enabling public health to come to the table in discussions with local authorities and other sectors with some budget of their own to address partnership working. If you go into a partnership and you have no money to offer, then you are in a very weak position. That money is for seed money to encourage initiatives which, as we discussed earlier, have a more general benefit but a particular health focus. It is encouraging others to come along with that. Again, in terms of Health and Well-being Boards, it is looking at what resources they can bring to the table to start bending mainstream spending. You will only really achieve the big gains when you address the mainstream budgets for education and housing and so on, but you need to have some money to start initiatives in those areas.

Professor Morris: If I may, it is quite easy to say that the proposed £4 billion is not enough. That is a fairly knee-jerk reaction. Actually, it is easy to build a fairly convincing case that it is not because of the way in which the figure was assembled. You have seen the tables, but, essentially, it is based on a report-this one-which is basically an estimate of prevention expenditure in England in 2006-2007, defined according to some very specific rules as to what ought to count as prevention according to OECD guidelines in there when they produced the health accounts.

With that in mind, it is easy to say why, given what, in the public health White Paper, this budget is supposed to be spent on, it is probably not enough. Very briefly, I can think of three reasons. One is based on what Professor Goldblatt has just said. This is money that is spent on prevention activities. It is not anything to do with the health promotion bit and the partnership between the NHS and communities. That is not covered there-essentially because it was not asked for in this information. That kind of activity would not be covered by the £4 billion or-I am sorry-what the £4 billion would cover is only an estimate of the current cost of prevention activities, not the cost of that promotion.

The second issue is that, even if you buy into this £4 billion for prevention activities, that is an estimate of current spending-and, of course, that assumes that the current spending on prevention is appropriate. To give you one example, the prevention expenditure figures here include things like the national Bowel Cancer Screening Programme. At UCL we have done a lot of work on the uptake of that and, currently, 54% to 55% of people eligible for screening actually do it. If you look at the split, in the richest areas it is about 60% and in the poorest areas it is about 35%. There is a lot of variation. You could argue that the current level of spending is inappropriate.

The third reason is a slightly picky kind of thing that an economist would say, and I apologise for that. The £3.7 billion figure is for 2006-2007. Obviously, there is not a lot of difference between then and now, except also in this report they present time series data. What they show is that between 2000 and 2006-2007 the figure on prevention at least doubled. What that would say is, if you are drawing the line, you would end up with a lot more than £4 billion. One of the things I wanted to suggest was, if people are considering going in to bat with that figure, it seems to me that analysis ought to be updated to try and get a more accurate figure on the current level of prevention activities.

Q203 Chris Skidmore: When the table that has been finally provided with the total prevention of public health services gets to the £3.7 billion figure by removing the £1.4 billion spent on medication, what would be the rationale to remove the medication element of the public budget?

Professor Morris: It is because it is captured by another bit of the resource allocation. There is a particular prescribing budget. The difficulty would be working out how to split that. I think that is why it has been taken out. That is mainly, often, going to be the spending on statins and cholesterol-lowering drugs, but that is covered elsewhere.

Q204 Chris Skidmore: As to this £4 billion budget, obviously, in terms of the budgetary restraints over this CSR period, we have a flat £4 billion even if it is, in real terms, an increase of 0.4%. Whether it is ring fenced-I guess they will also have that small real-terms increase-but what you are saying, for instance, is that, as a result, if you have the success of proportionate universalism taking place of bowel cancer screening, even if it goes through that 32% or whatever up to the 54%, you get a levelling out. By necessity, the public health budget almost needs to be ring fenced in a way that it will increase on that sort of gradient because it is only going to be a victim of its own success.

Professor Morris: Yes, that is right. More importantly, this is prevention and it does not include the cost of all the health promotion activities, which might be partnerships for, say, building more playgrounds, fire and rescue services providing home safety checks and that kind of thing. That kind of activity is not included in these figures. My reading of the White Paper is that this health premium is the sort of thing which is supposed to be funded by that and that is supposed to be coming out of the £4 billion but was not actually in the figures we used to calculate it. Does that make sense?

Q205 Chris Skidmore: Yes. In terms of breaking down the budget and how resources might be allocated to more deprived areas, obviously PCTs had a weighted capitation formula that focused, almost singly, on helping deprived communities. I believe, Professor Morris, you have done some work on that.

Professor Morris: Yes.

Q206 Chris Skidmore: Now we have had this reorganisation and we are going to see, obviously, PCTs eventually disappearing by 2013, what work do you know is going on to look at replacing the weighted capitation formula and how it will be implemented? How can we ensure that the budget is in place by 2013 that will provide this gradient approach, so that not only will we have the gradient in terms of intervention but we will have a gradient in terms of the finances?

Professor Morris: Do you mean with respect to the public health moneys or more generally?

Q207 Chris Skidmore: More generally, in terms of focusing on health outcomes for those deprived, ensuring that the money which is in place, certainly for primary care, ends up being directed to those most in need.

Professor Morris: Okay. I will try and give as brief an answer as possible, although it is hard to be too brief. One specific element of the weighted capitation formula which is designed specifically for that is the health inequalities adjustment. More generally, the aims of the formula are equal opportunity of access in reducing and avoiding inequalities. Arguably, all of it is designed in some way for focusing on the more deprived populations. Whether it has achieved that is a matter of some debate but, arguably, that is the aim of all of it. However, the bit that seems particularly relevant in the context of public health is the health inequalities adjustment.

Q208 Chris Skidmore: That will be taken into account for the local public health budget, you believe.

Professor Morris: The health inequalities adjustment is currently applied to 10% of allocations; it used to be 15%. Essentially, it is based on the level of health in an area. We did a small project for the Department of Health recently, looking more closely at it. It seems that the aim of this particular adjustment has three things it is supposed to be trying to achieve. One is this prevention activity, the second is the health promotion activities, which we have just talked about, and then there is this third element to do with unmet need with regard to treatment. While there is an amount of budget allocated according to it. How it should be broken on those three things is not very clear. My understanding is that, with the public health budget, that might take away those first two bits but the third one would still remain within the remit of the rest of the weighted capitation formula.

One of the issues about that particular adjustment is that it is not ring fenced. Therefore, it could all be spent on treatment, for instance, to quote an extreme case.

Q209 Chair: Do you understand how this formula is supposed to work, bearing in mind that the largest single item of this £3.7 billion is payments to general dental practitioners and payments under the QOF system that are all national contracts? It is not clear to me how the systems are supposed to interface with each other.

Professor Morris: We are in the dark as to how the £4 billion, or however much it is, is supposed to be allocated. I can only presume it might be according to the current method used in the health inequalities adjustment, but that is speculation on my part.

Q210 Chair: Presumably the budget holder in local government will be bound by the contract with the general dental practitioner and with the general medical practitioner under QOF.

Professor Morris: Yes.

Professor Goldblatt: I think the £4 billion is a post hoc calculation of how much was spent. The allocation of money goes down different routes. Money goes to acute care spending and also goes to GP practices. At the moment, the proposals are that more of that money will be diverted through GP practices. In fact, as Professor Morris said, there is no way in the current formula of ring fencing that. Once money is given, as in the past, to PCTs or GP practices, it was down to their discretion how they spent it within the targets that were set for them. A lot of the money that went to GP practices was to meet their vaccination and immunisation targets. That is, as you said, is one of the biggest components. Although that is not ring fenced, it is constrained by the way in which the target system worked for GPs. That is how central Government controlled expenditure, but there were no similar targets for GPs doing health promotion activity to the extent that there are for vaccination and immunisation.

Q211 Chair: I want to bring Grahame in, but I don’t understand what levers the local authority has to pull, in particular if we are going back to a national contract for GPs. We already have, as I understand it-but I am open to correction-a national contract for dentists.

Professor Morris: I agree with that and it comes back to what I saying before about the idea that this £4 billion is essentially based on that specific set of themes. There might be things over and above that-the health promotion angle-that the local authorities might or ought to be responsible for which does not seem to be accounted for in the £4 billion.

Q212 Grahame M. Morris: I would like to ask some questions about the health outcomes framework but, before we move off that issue about the ring fencing, I wonder if I might ask this of Professor Morris. His colleagues may wish to comment as well. It seemed to me positively a good thing when it was announced there would be a ring fence for the public health moneys. However, having looked at it in a little more detail, and given that half of it goes to the GPs for the prevention of non-communicable diseases, which is also a good thing, what is the downside to ring fencing the public health budget-just for the record?

Professor Morris: I would say the potential downside is that one needs to be very clear as to what is included in that-I am not sure whether it is the "ring" or the "fence"-to make sure you do not try and pile in all and sundry. As you said, some of the money might already be accounted for and you need to make sure there is enough left for all these other activities. That is the issue.

Q213 Grahame M. Morris: I wonder if I might move on to the Government’s public health Outcomes Framework. This is going to be the yardstick by which improvements in public health are to be judged. We heard, earlier on, from Professor Goldblatt and Dr Allen about the six key recommendations of the Marmot Report. Do you think they should be the cornerstone of the public health outcomes framework? I would also like to know how we will measure these outcomes of performance.

Professor Goldblatt: Yes. We would say, wouldn’t we, that we thought our recommendations and the framework we developed for outcomes should be the cornerstone? It has turned out that they play a part in that, but not as large a part as we would have liked. In particular, if you look at all the outcome indicators, there is a matrix that shows which of them are available or not on the basis of inequality. At the moment, very few of the outcomes are available to measure individual inequalities or inequalities between neighbourhoods. To be successful, a greater proportion needs to be.

In our report, we identified a small number of key indicators which we thought were crucial. I think, from what we said earlier, it does not take much to guess what those were. The first one we identified was both life expectancy and healthy life expectancy and their social distributions-their distributions across neighbourhoods. Those are reflected there but in order to monitor measurement of them on a regular basis more work needs to be done.

Secondly, we identified, as an outcome of early years, readiness for school as an indicator and, again, the social distribution of that. As I said, we commissioned the London Health Observatory, early in the year, to start the ball rolling on monitoring that-independently of the outcome framework, but it should be in there. When we produced our report, we said that there should also be, aspirationally, a measure of well-being, and that would need to be developed. We were overtaken by the Government coming in afterwards and the Prime Minister saying there should be an indicator of well-being. A lot more development work needs to be done to define how well-being relates to health.

We also identified, as an important indicator, the number of people not in education, employment and training, which is linked both to successful schooling, in that they are able to take up employment or education, and also to the employment environment. Those were the ones we highlighted as being key indicators. As I say, we produced our own framework, which we think is necessary to look at some of the processes in moving towards better health, in order to monitor progress across the life course.

Q214 Grahame M. Morris: Following on from that-you have come on to the point that I wanted to raise as a supplementary-in your written evidence to the Committee on how we would monitor progress in tackling public health, you have mentioned some of those indicators about life expectancy and readiness for school, variations across neighbourhoods and so on. I wanted to ask, because it is a bit of a hobby-horse of mine, about the future role of the Public Health Observatories. Would you say that they were key in assessing how well we are doing in tackling health inequalities, looking at the evidence and doing the benchmarking and yardsticks between areas and so on?

Professor Goldblatt: Absolutely. They have a key role to play. It needs to focus on the wider determinants of health and they need to move towards that, as many of them are. The important issue is that we have to look at the changes going on in the NHS and public health as a whole and say, "Is the information expertise in the NHS in the right places?" We said in our submission that, as we move to GP commissioning, it is not a traditional part of GP work to do population-based needs assessment. That has been sitting, in the past, within PCTs and supported by the Health Observatories. We are now seeing several of the Health Observatories, under threat, losing key expertise and the expertise that remains is with people, generally, on short-term contracts. As we mentioned earlier, there is a two-year gap between where we are now and where the reforms will be in 2013. In two years, a lot of expertise can be lost.

Q215 Grahame M. Morris: Is it fair to say, Professor Goldblatt-and I don’t want to put words in your mouth, but it is important for the record-if we are going to effectively measure public health outcomes then we need an effective public health observatory system to do that?

Professor Goldblatt: I would say that we need an effective system for monitoring public health, and for two reasons: one, to ensure needs assessments are done in order to implement proportionate universalism. You cannot do that without a needs assessment. The Joint Strategic Needs Assessment in place at the moment provides that starting point-QOF provides that starting point-and more work needs to be done on those.

You need organisations that have the information and intelligence expertise to provide that to the GP commissioners. Secondly, as you rightly say and as we emphasise in our report, you need a monitoring framework to see how we are progressing, not just on the end outcomes, like life expectancy, but along the process that is necessary to move to that. At the moment, the Public Health Observatories are providing a large part of that. Some of it was provided within PCTs. The PCT element is disappearing quite rapidly so what you are left with is the Observatories. There is a need to fulfil the role that Observatories are playing.

Q216 Chris Skidmore: Regardless of that, Professor, am I right in saying you would probably agree that, generally, the information we have on patient care records and the availability of that to be analysed is woefully inadequate compared to other countries? If you look at Denmark, for instance, a much smaller country, they have a system where they can analyse public health data because the data exists. You mentioned about NEETS and things like that but all that data is open to easy manipulation.

I can remember looking at the staffing, say, for NEETS-the 16 to 18-year-olds. It has risen rapidly but that does not take into account the number of kids going off on a gap year, for instance. There are lots of ways in which the data can be used, but until we have a system that will bore down to individual level your job is going to be a lot harder. Equally, a lot of the outcomes-life expectancy-you can’t really measure over a single year. You have to measure at least five years, if not 10 years. The benefits of the recommendations in your report will not necessarily be apparent until several years down the line. Would you agree?

Professor Goldblatt: Yes.

Q217 Chris Skidmore: At what point would you say an intervention becomes apparent and the evidence is there?

Professor Goldblatt: There are several points I need to answer from that question. The first, which relates to my previous point, is that what we did in terms of our own framework of indicators was to define process, output and outcome indicators so that, in terms of the life course approach, you can see you are on track to be delivering those ultimate health outcomes like life expectancy. By going through those processes which generate ill-health, along with the social and health processes, enables you to check that you are making progress in the early stages of the development of social disadvantage and of health disadvantage. We spelt out the details of how you would do that.

You are quite right that the information systems we have in this country, while better than those of many countries, are not as good as Scandinavia’s. They are not as good as Scotland’s; we do not have to go as far as Denmark. Scotland has very good link data, dating back to decisions in the 1980s to have a health identifier which links to other systems. We do not. However, a lot of work has been done and I do not think we are making best use of the systems we have. For example, the NHS Information Centre has mortality records by GP practice which could be made more use of in terms of t linking them to other types of record.

Q218 Chair: They could be made available to the patients.

Professor Goldblatt: Yes.

Q219 Mr Sharma: How important is coterminosity between the various players in the NHS and public health systems in addressing health inequalities and measuring outcomes?

Professor Goldblatt: Coterminosity has always been important in delivering partnership working. There have only been two or three years, in its history, where the NHS and local authorities have been coterminous. That has created huge difficulties in creating partnership working when it is not clear, for some of your population, whether you should be partnering with your major local authority partner. As to needs assessment, it is essential that you can jointly do a needs assessment for health which links to needs assessments in terms of housing and education.

In those technical terms, coterminosity is important but when we go on to monitoring, again, it is challenging if you don’t have coterminosity but on the ground if you are a GP commissioner and you are not coterminous with the local authorities who can deliver improvements in housing, in health, etcetera, it means you are having to deal with several local authorities covering your patients. That does not facilitate partnership working.

Dr Allen: Also, in relation to accountability for public health, there needs to be some element, both in terms of the discussion about monitoring and in terms of the coterminosity, for the public to know who is accountable locally for public health. That would be amplified if there was coterminosity.

Q220 Mr Sharma: The Government proposes that the health premium will be paid to those local authorities that show the greatest improvement in public health. How effective could this be, particularly in respect of tackling health inequalities?

Professor Goldblatt: What we have said earlier is that, for the most affluent areas, achieving health gain is, in relative terms, the easiest. It will be easier for the local authorities that have the most affluent populations to achieve the targets needed to get the health premium. Conversely, areas of great disadvantage could put a lot of effort in but, in terms of the achievement, will achieve a lot less and will, therefore, get a lot less money from the health premium. The health premium being implemented in a very crude way risks being regressive rather than progressive, with more money going to the most affluent areas and less to the least well-off areas.

Q221 Chair: Professor Morris, have you looked at the health premium and how that would work in terms of resource allocation and the effect of the application of the principle?

Professor Morris: No. I am not aware of research that has gone on at all to identify the size of the premium. I agree with the comment just made by Professor Goldblatt. However, going back to what I said before, a very positive aspect of this, which we ought not to lose sight of, is that this seems to be all about health promotion. This is not the prevention bit. This is the bit of the budget that is to do with promotion and working together across communities over and above the prevention activities. In that sense only, I think the health premium is good but, as we heard, the devil is in the detail as to how to make the allocations.

Q222 Chris Skidmore: What economic research has gone on, independently of your own research, into health premiums and their effects? There must be some research somewhere. They would not just introduce a premium blindly without having any-

Chair: Discuss.

Professor Morris: There has been some work, and we quoted this as well-this was something I omitted to mention to your question before-looking at the relationship between funding and health outcomes: how, if you give more money to an area, its health goes up or down. I don’t want to bore you with the details, but it is quite complicated because you give more money to areas that are less healthy where you would expect the health to be worse. There are various bits of work, and an increasing body of work, being undertaken at the moment to say that if you give more money to areas the average level of health in that population goes up.

We did some work, when we did a small project for the Department of Health looking at the health inequalities adjustment, looking at the relationship at all course funding on disability through life expectancy. As an example-and the results were quite tentative-we found that if you spend an extra £100 per person in an area, the disability-free life expectancy goes up by about 0.8 of a year. That was a positive effect. One of the things I was going to suggest, and it is something I forgot to mention before, is that, in terms of the funding, that is another approach that ought to be used, which embeds quite nicely with the health premium. However, it is not fit for purpose at the moment. My understanding is that there is not an algorithm that can be used to "push the button and go". There is more research that needs to be done to investigate it.

Q223 Chris Skidmore: I guess another approach is that if you sort out problems like middle class drinking, for instance, that leaves a greater resource available in the longer term for the budget to be spent on more deprived areas which have, maybe, more chronic conditions.

Professor Morris: Yes.

Q224 Dr Wollaston: Is another case for proportionate universalism saying that, with the health premium, you make the premium greater for disadvantaged areas and less or would you have another thought about how you would recommend the Government adapts this? Would you say scrap it altogether and use something else? What would be your recommendation?

Professor Goldblatt: As you say, it needs to be focused on more disadvantaged areas. Following your logic, it is the most advantaged areas that have the greatest number of middle class people whose health problems you can sort out more easily, so it is the most advantaged areas that would gain most from a formula which was not proportionate. It needs to be focused either on the socioeconomic characteristics of the area or on providing an incentive for the areas that have furthest to go in terms of achieving health gain. I am not prescribing a particular way of doing it; I am simply saying the end result needs to be progressive rather than regressive across areas.

We mentioned, earlier, the fact that, as with the existing resource allocation, you give the money to a commissioning area. You do not then, on the whole, have a say about how it is spent within the area. Again, this comes back to the point about monitoring. You then need to be monitoring the outcomes in those areas and across people or across neighbourhoods in an area to see how, locally, the money had been spent and whether it was reducing inequalities within the area.

The history of health in this country is that we have seen progressive improvements in the health of all members of the population for quite a considerable time. However, what we have seen is parallel increases that maintain the inequalities between groups within areas. Everyone’s health, for some 20 or 30 years, has been increasing. The trick, as far as we are concerned, is to achieve greater improvements in health among the least advantaged areas and among the least advantaged individuals.

Q225 Yvonne Fovargue: How satisfied are you that there will be an adequate public health input into NHS commissioning to ensure that the inequalities in service provision and access are identified? You have raised concerns about Health and Well-being Boards. Do you feel that ours are now strong enough?

Professor Goldblatt: There is not enough evidence, yet, on how our Health and Well-being Boards will operate. There are certain indicators which suggest, as we indicated in our written response, that the public health input needs to be strengthened. The role of the director of public health on the Health and Well-being Board needs to be stronger and the advice available to commissioners and to Health and Well-being Boards needs to be strengthened. We were talking about the role that Public Health Observatories might play. Again, you also need people in the local area who can provide that public health expertise.

At the moment, with this two-year interregnum, we are seeing a loss of public health expertise at local level. It is not, like any profession, something you can re-gain once you have lost that expertise. We have seen that in some of the other NHS reorganisations in the past. It took some time to re-gain that kind of expertise. There was a long period when there was a huge shortage of directors of public health. We now need to be moving forward in terms of a greater diversity of expertise among directors of public health. There has been some movement in that direction over the last few years, but we need further movement in that direction and, at the moment, while we go through this interregnum, we seem to be moving in the other direction.

Q226 Yvonne Fovargue: Can I quickly raise the issue of fragmented commissioning of the public health? Concerns have been raised before, and particularly about children’s services. What implications does this fragmentation have for health inequalities?

Professor Goldblatt: As I said earlier, we are very concerned to see partnership working and what we called a whole-of-Government approach. At a local level, that is typified by whole-school initiatives where social services and health and education are all working together with the children right across the social spectrum. It is not solely about the most disadvantaged or the most at-risk children; it is about providing proportionate services, again using Sure Start centres to provide proportionate interventions. That needs to be joined up. There needs to be partnership working. If mainstream budgets are not tied to these sorts of objectives and are held on to within silos, it will be much more difficult to implement the sorts of initiatives of policy change at local level that we were recommending.

Q227 Chair: On that note, we need to move on. Can I ask the witnesses whether there is something you have been burning to say that we have not asked you?

Dr Allen: There is one point we made in the report that puts some of the discussions we were having about costs and so on in context. We had a team of economists which estimated the costs to the economy of health inequalities. They said that, as a result of health inequalities, you see productivity losses of £31 billion to £33 billion-this is every year; lost taxes and higher welfare payments in the range of £20 billion to £32 billion; and additional health care costs-and I think this is a very conservative estimate-to the NHS as a result of health inequalities of £5.5 billion. That is a huge financial cost, let alone the cost to individuals in terms of illness and early death. The costs to the economy are very significant. It puts the discussion we were having about the size of the public health budget in some sort of context.

Q228 Chair: These are estimates referred to in the Marmot Review, are they?

Professor Goldblatt: Yes.

Dr Allen: Yes.

Professor Morris: I did calculate that figure. That is in a Department of Health report.

Chair: Thank you.

Q229 Grahame M. Morris: Could you send us a note about that? It would be helpful if you could, unless it is already in the evidence and I have missed it.

Professor Morris: Yes.

Grahame M. Morris: Thank you.

Professor Morris: Very quickly, it is important to think of the funding at three levels. The first level is what the size of the national budget ought to be, and I hope I have given fairly compelling evidence that I do not think £4 billion is enough.

The second level is how to allocate that money to areas, and I suggested that there are two broad approaches to do with this: distribution of ill-health like the health inequalities adjustment or according to the relation between funding and health outcomes.

There is then the third question, which we have not really touched on: what should the areas do with the money once they have it? I guess that is left for local decision and that is partly what is in the White Paper. However, one small point is that one of the things I do is sit on the Public Health Interventions Advisory Committee at NICE, and we make recommendations about how funds ought to be spent locally to improve public health. For some reason, the workload of PHIAC has reduced dramatically. Since December last year, we have not met and, usually, we meet monthly. Everyone is a bit mystified. It seems to me, at a time when one wants to be providing more guidance to local areas about how they ought to spend public health money rather than less, those kinds of activities ought to be beefed up rather than reduced. Thank you.

Chair: Thank you very much.

Examination of Witnesses

Witnesses: Dr David Halpern, Head, Behavioural Insights Team, Cabinet Office, Professor Sir Ian Gilmore, Chair, Alcohol Health Alliance, Mark Baird, Head of Corporate Social Responsibility, Diageo Great Britain Limited, and Chris Arnold, Creative Partner, Creative Orchestra, gave evidence.

Q230 Chair: Thank you very much for coming and thank you for sitting through most of the previous session as well. Could I ask you, briefly, to introduce yourselves and tell us where you are coming from?

Professor Gilmore: Thank you. My name is Ian Gilmore. I am a physician in Liverpool and a professor of medicine at Liverpool University. My specialty is liver disease, which is why I developed an interest in alcohol, which is responsible for about 80% of liver deaths. While I was President of the Royal College of Physicians, I set up the UK Alcohol Health Alliance, which now comprises 32 health organisations who are concerned about the impact of alcohol on health.

Dr Halpern: I am David Halpern from the Cabinet Office Behavioural Insight Team, which I head. Essentially, our work is to look at other ways in which you can affect behaviour across a range of policy areas. We have looked at health as well as a number of other areas too.

Chris Arnold: My name is Chris Arnold. I am a marketing and advertising expert. I run an advertising agency. I used to be at Saatchi & Saatchi. I also wrote the book Ethical Marketing and the New Consumer. I have sat on the UK’s largest trade body for marketing. I have also chaired the Agencies Council for ad agencies and the Creative Council.

Mark Baird: Good morning. My name is Mark Baird. I am Head of Corporate Social Responsibility for Diageo Great Britain. Over the last couple of years I was seconded into the Scottish Government Alcohol Policy Department, working on the Scottish Government alcohol industry partnership. I have extensive experience of working with and within Government in improving public health and areas of tackling alcohol misuse and I have been involved in drafting Diageo’s responsibility deal pledges.

Q231 Chair: Thank you very much. We would like to start, if we may, by addressing some questions to Dr Halpern specifically, because one of the concepts at the heart of the Government’s approach to public health is what is referred to as "nudge", which I guess is a popularisation of the result of a Behavioural Insight Team. We would be interested to hear you explain to us how your department works, what we should understand by the concept of nudge and how you work with the Department of Health to develop that as a public health tool.

Dr Halpern: I am certainly very happy to do that. As to nudge, interestingly, the original title for that book with Richard Thaler and Cass Sunstein was "Libertarian Paternalism". His publisher advised him that this would be a better term, and indeed it was, as I think we can all agree.

The essence of the idea is quite a simple one. All kinds of complex factors affect our behaviour and you can work with them, ideally leaving as much agency as possible with the individual but none the less having a big impact. As you may or may not know, I did a previous stint in Government-I have, otherwise, often been in academia-and while at the Institute for Government one of the reports we did was something called MINDSPACE, which was essentially trying to boil down some very large literature indeed now about various kinds of behavioural effects. Every time you go into a laboratory it feels like a new effect or result is found.

Partly, the challenge is to work out which ones are robust and might work in the field versus which ones just melt like the dew in the morning sun. We put together-in fact, it was commissioned by the previous Administration, at the tail end-a report called MINDSPACE which is, essentially, a way of summarising the main kinds of effects: messenger effects, incentives, norms, defaults, etcetera. Maybe we will talk about some of those as we go along.

They can be used in lots of areas. You asked specifically about our work with the Department of Health. If you had a look across many policy areas, health is one which is surely going to spring to mind. We know, from lots of data, that more than half of all years of healthy life lost are to known behavioural factors-smoking, drinking, diet and so on. Yet, only a small fraction of our effort, both our formal spend but even our research spend, is spent on behavioural factors. A remarkable figure actually came up through the Darzi Review that, just to take the research issue alone, less than 0.5% of health research, which is very substantial, is on behavioural factors. Of that, most is medical compliance-when people take their pills. It is a striking juxtaposition between the sheer scale of the behavioural effects as opposed to the effort we spend focused on them.

We work with the Department of Health. We cannot claim to be health experts, particularly, but "Let’s see: how can you use these kinds of approaches?" Alongside the White Paper on public health, which makes a lot of reference to the use of these approaches, a document came out, around the new year, giving some examples of those sorts of approaches. I will give you a nice recent experiment on social norms. Social norms are a powerful effect. We don’t do things because they are the right thing to do; we do them because that is what everybody else is doing. Right? When you come into the building, as to whether you use the doors or the bit that turns in the middle or the lift depends a lot on what other people are doing.

To illustrate that-a little health example in a recent study-someone tried putting up a sign where the lift is and the stairs. They try a health sign saying, "It’s much healthier to take the stairs; why don’t you do it?" It has absolutely no effect whatsoever, as is often true for many informational campaigns. On the other hand, they then use a sign which says, "90% of people take the stairs." It wasn’t necessarily true, but they put the sign up. What happens is there is nearly a 50% increase in the number of people who take the stairs. Not only that but, when you take the sign down, it carries on. It is an effect which is persistent. There is a simple, everyday example of using a kind of nudge-in this case, giving people information about what other people do. It can be very powerful. It is sometimes called channel effects. What look like irrelevant details of policy design or what goes on can often be very big. That is basically what we were doing in health, as we do in other areas.

Q232 Dr Wollaston: I was wondering what the evidence base is for nudging. Could you elaborate a bit more? You have given the example about the stairs but in other areas of life-for example, in the Government’s police on alcohol-how strong is the evidence base for what they are doing?

Dr Halpern: There are two kinds of evidence, of course. There is a very wide evidence base from many areas. Indeed, partly, our role is to look at what works in another area and say, "Would it work in health?" If you move to health, more specifically, then you get to a smaller field of evidence. Obviously, one of the conversations today is going to be about alcohol but, to take a social norm example to follow that through, there has been a lot of work about whether people mis-estimate, make errors about-

Dr Wollaston: "Misunderestimate"? That is a coin of choice.

Dr Halpern: -how much you think other people drink. You can see why it will happen. If you are a student on a campus, you don’t hear the students who are busy studying in their rooms, but you do hear the ones who are drunk and stumbling through the campus at 1 o’clock in the morning. We know that there is a systematic overestimate by people about how much they drink, or indeed by students about how much other students are having, and lots of other things too. There are a number of trials being done in the US, and a particularly famous one in Montana, using this example-

Dr Wollaston: Yes. I have seen that.

Dr Halpern: -where, if you give people more information about the social norm, that itself affects behaviour. That doesn’t mean to say there aren’t lots of other things that affect behaviour like price-to anticipate some other line of questioning. We know price is important to lots of things, particularly where there is an alternative product which is available. Therefore, there is a fair amount of evidence. It is particularly strong when you look in other areas. When you apply it specifically to health, or any given issue, of course the field becomes smaller. That is one of the reasons why this work has to be very empirical. It is characterised by the fact that you have to do trials and find out whether or not it works in the field? Of course, that is what happens in marketing. It is just that Government doesn’t do much.

Q233 Dr Wollaston: I meant specifically for the Public Health Responsibility Deal. What kind of evidence base is there that that is going to work?

Dr Halpern: It is early days, of course. You would have, for the most part, to look at where it stems from. A nice example, and a particularly good example on health responsibility, is salt. There is good evidence that, if we reduce salt, lots of downstream consequences follow as well. There are some precursors of it. Some EU work suggests that you can get manufacturers to adjust their salt levels, and we know that people cannot tell absolute levels of salt. It will all amount to a strong package that suggests, assuming it sticks-I do not know if that is in your question-and assuming there is a follow-through and it is implemented, yes, if you reduce salt levels, people won’t notice the salt level and there will be far fewer strokes and all the rest of it. One has to take it issue by issue.

Q234 Chris Skidmore: On the responsibility of salt specifically, to take that issue, the research showed it reduced salt intake by 0.9 grams but if you look at Japan and Finland, which, obviously, took a legislative approach, they reduced salt intake by 5 grams. At what point do you think a nudge becomes ineffective and you need to go further? Salt is a very good example of where you are able to go a lot further by taking extra action beyond the nudging process.

Dr Halpern: You can go further. Of course, you can regulate. That is partly about what you want to do in any given issue. Health is also interesting because it has such a range of behaviours that we are talking about. In some cases it is obvious we are talking about regulation and, in relation to smoking, we have been for a long time. In others, there is much more hesitancy to do so.

One of the advantages of some non-regulatory and voluntary agreements is that you can implement them quite rapidly. Of course, well constructed regulation is a subject where we have many examples of well-intentioned regulation which leads to various kinds of perverse effects. If you can get a genuine hearts-and-minds engagement and solve some of the collective action problems around some issues, then you can achieve very substantial change using non-regulatory tools.

Q235 Chair: Would it be fair to characterise your position that there is the opportunity to change behaviour through nudge and through promotion and we need to test how far we can change behaviour and whether that is enough in a given set to deal with a particular issue?

Dr Halpern: Yes. Indeed, in terms of responsibility, "Let’s roll up our sleeves and work with the major players who affect our behaviour in an everyday sense and let’s use all the tricks that are available to us", frankly.

Q236 Chair: Mr Arnold, you introduced yourself as a professional marketing guy. How realistic is this?

Chris Arnold: Behavioural economics and things like social norms is something in our business we understand quite a lot, actually. It is interesting that, usually, the message you get through the media and the Government is that everybody is getting drunk, everybody is having sex and everybody’s smoking. That is the worst thing you can be saying because you are telling people that is the social norm; what you need to be doing is the other way round.

When we did the One Too Many campaign, a Drinkaware campaign run in all the colleges over about 10 universities, we found out that, when we did the surveys afterwards, a lot of students went out drinking because they thought that was the social norm. You actually found, in some of the groups, that a lot of them did not want to get drunk. They just thought that is what you are meant to be doing. If they had all been very open with each other, they would have said, "Actually, only about one of us wants to get drunk. Maybe we shouldn’t."

There is an enormous amount to be done in educating people. As David said, if you tell them the truth, that most people aren’t getting drunk-most people aren’t getting trashed and they don’t all want to get bladdered-a lot more people behave more responsibly. I think that applies in sexual health and other areas. I used to work for Family Planning as well and I used to be on the board of Family Planning. We had very similar issues with that. If you ask people, everyone thinks they are having sex. The reality is that most of us don’t have sex till we are 19. The perception is that we should be and we are.

Q237 Grahame M. Morris: Can I ask a conflict of interest question, Chairman? Clearly the industry and the representatives who are giving evidence in this session are opposed to the idea of regulation and legislation and would rather have voluntary agreements. You support the nudge philosophy. Is there a conflict of interest here between your commercial interests and the impact you have had in terms of policy formulation?

I have been looking through the Register of Members’ Interests and I note that Ian Wright from Diageo made donations to Nick Clegg’s office and that Andrew Lansley was a paid director of Profero and his clients were listed as Pepsi, Mars, Diageo’s Guinness and Pizza Hut. Of course, Mr Lansley’s wife runs a consultancy called Low Associates, and Kraft is among the clients listed there. Is there a reasonable issue of conflict of interest? How can we legitimately take your point of view when you have a clear commercial interest in not regulating?

Chris Arnold: Personally, I can answer that. I used to sit on the board of the DMA, which is Europe’s largest trade body. As I said earlier, I used to chair the Agencies Council. There is not, actually, an aversion to a certain amount of legislation anyway. In some cases, I think some of us genuinely believe that in certain areas it is not such a bad thing. There is a lot of legislation in the drug industry, for example.

Picking up on a point that you mentioned earlier about subliminal advertising, we are not allowed to do subliminal advertising. It is illegal. There is a lot of regulation already. Sometimes it is not a bad thing to bring it in. Other times it is good to have the industry enforced. We have very strong self-enforcement laws, the ASA, CAP and the DMA. We have very strong laws within the industry that we have to obey. You can’t stop those who work outside the industry from abusing it, but these are not the people we are talking about today.

Q238 Grahame M. Morris: In terms of influencing opinion and putting moneys into health promotion campaigns, say, for example, for Diageo-is it one of your clients?

Chris Arnold: Yes, I work with Diageo but only on the One Too Many campaign which is by Drinkaware.

Q239 Grahame M. Morris: Do you have any knowledge, in general, what proportion of Diageo’s profits would go into such health promotion campaigns?

Chris Arnold: Absolutely none, I am afraid. I do not have that information.

Q240 Chair: Does Mark Baird know?

Mark Baird: We put 1% of our pre-tax profit globally each year into CSR.

Q241 Grahame M. Morris: How does that compare with the profitability of the brand and of the company?

Mark Baird: We don’t report those financial figures at a GB level. Those are at a global level where we make £2.24 billion but we do put 1% of pre-tax profit into CSR. In the UK, that amounts to a seven figure sum. For example, in the UK alone we put over £1 million into Drinkaware and that is between subscriptions to Drinkaware themselves but, also, into activating the "Why let good times go bad?" Drinkaware campaign. In GB, just on responsible drinking, it is a seven figure sum and at least £1 million of that goes into Drinkaware as well as all the other campaigns that we put into up and down the country.

Q242 Chair: Can I bring in Professor Gilmore?

Professor Gilmore: Yes. I don’t think I have any conflict of interest other than the influence by the young people I see dying in the wards most weeks. It is a difficult issue. I was involved with setting up the Drinkaware Trust, which is a charity and is funded purely by industry. It took three months of very hard work and knocking heads together to get even 50% of non-industry people on the board of that, and it is very difficult still. I think the health community is not yet persuaded of the independence of Drinkaware and we are watching that with great interest.

Industry, clearly, has to be a partner or a player here when you are discussing the implications of public health policy and how that will affect the industry and jobs. However, I do have a problem when industry is in, at the start, developing public health policy. I think that is where there is a potential for conflict.

Q243 Chair: Could you elaborate on that? Is this in defining the targets that we are trying to meet?

Professor Gilmore: Yes; even the very approach to take. To parody this, most people would agree that the industry paradigm is that alcohol is a normal product, but a few people misuse it. Therefore, we should target that small number of people and let everyone else get on with life and take personal responsibility. Whereas the public health paradigm, which is very much adopted by the Department of Health in Scotland, is that alcohol is not an ordinary commodity. It is a drug. It is a drug of dependence and it is a psychoactive drug but it is legal. We are not trying to make it illegal. The problem is with the product. We have to try to make the environment less "alcogenic", if I could borrow the obesogenic term, and try to get away from the 24 hour, 7-7 exposure to alcohol marketing, alcohol sales and the cheap prices and use ways, both to nudge but to use firmer measures when nudging is not sufficient, to move people away from misusing that product.

Q244 Chair: Would you care to characterise your approach as looking for proportionate universalism in your message on alcohol?

Professor Gilmore: Yes. If it is a conflict of interest, I was a commissioner on the Marmot Review and learnt a lot about early-life experience that has, hitherto, been a closed book to me.

Mark Baird: If I can contextualise the responsibility deal for a moment by quoting from the World Health Organisation and their global strategy to reduce harmful use of alcohol, from last year: "The Secretariat would provide support to Member States by continuing a dialogue with the private sector on how they can contribute to the reduction of alcohol-related harm." Also: "The Secretariat encourages Member States to encourage active and appropriate engagement of the private sector and industry associations." The World Health Organisation actually encourages Member States to involve the private sector in tackling alcohol harm, not making policy. The two are very different.

Q245 Dr Wollaston: Can I also take you up on something else the WHO said-that because of the disproportion between spending on CSR and spending on marketing, the actual spend becomes meaningless? Wasn’t that their exact words? Can I ask you perhaps, further? You have mentioned that Diageo spend 1% of their pre-tax profits on CSR. How much of their pre-tax profit do they spend on marketing?

Mark Baird: We spend £1.4 billion on marketing.

Q246 Dr Wollaston: What percentage is that of your pre-tax profit, so that we can compare it with the percentage you said?

Mark Baird: It was £1.4 billion against £2.24 billion.

Dr Wollaston: I am sorry-

Mark Baird: £1.4 billion on marketing-

Dr Wollaston: You have spent £1.4-

Mark Baird: -billion on marketing globally, and there is £2.24 billion profit.

Q247 Dr Wollaston: So we can make the figures comparable, you said you spend 1% of your pre-tax profit on CSR-

Mark Baird: Globally. That is £224 million.

Q248 Dr Wollaston: Could you put them both into percentages for me? Do you know what the percentage is?

Mark Baird: I don’t have a calculator; I am sorry. Could I come back to your point on marketing versus CSR spend? I think it is an invalid comparison. You are making the assumption that our spend on marketing is promoting irresponsible drinking. You are almost making a comparison that our marketing of our brands is fighting against our responsible drinking campaigns, when that is not the case. Our brand marketing activity is not promoting irresponsible drinking. Therefore, I would suggest it is an invalid comparison to match that against the activities we do which promote responsible drinking. I would also say that the brand marketing campaigns we have all carry the drinkaware.co.uk brand name and website address. Therefore, all of our brand marketing is, actually, promoting responsible drinking.

Q249 Dr Wollaston: To pull you up on the proportionality, I was looking at the back page of a well-known Sunday paper, which of course is going to be very clearly visible to children. If you look at the size of the promotion and then at the size of the Drinkaware logo, you would need to have very good eyesight to see it. I think, again, there is an issue about how prominently that is placed. Also, can I ask you to go further on the amount you spend on marketing? Would that include sponsorship in that figure?

Mark Baird: Yes, it does.

Q250 Dr Wollaston: For example-going back, perhaps, to subliminal marketing-it is a great concern to many people that the FA Cup is now going to be sponsored by a drinks brand. Would you say that is a form of subliminal marketing, the link between sporting success and alcohol? We know, obviously, under the Portman rules, you wouldn’t be able to imply that alcohol led to sporting success, but do you think there is an issue there about subliminal placement?

Mark Baird: You are absolutely right. The Portman Group Code doesn’t allow us to associate alcohol brand with sporting success. I think you are making a great leap to say that the sponsorship of a tournament is implying success.

Q251 Dr Wollaston: You don’t think a link would be made in some people’s minds in having a very heavily marketed brand directly against a major sporting event seen by children worldwide.

Mark Baird: We are very clear that we are not allowed to link sporting success with alcohol, so we don’t.

Q252 Dr Wollaston: Why do you sponsor?

Mark Baird: The rules, as you well know, for alcohol marketing is 75% of the audience and above would need to be over 18, which they would be.

Q253 Dr Wollaston: Many people would say that should be a 10% cut-off rather than a 75% cut-off.

Mark Baird: I am aware of that.

Q254 Dr Wollaston: If you think of just the proportion of the general population, what proportion of the general population are under 18?

Mark Baird: I don’t know those figures.

Q255 Dr Wollaston: In other words, it doesn’t really cut it off, does it?

Mark Baird: The 75% rule has been in place for some time. It seems to work. Our marketing regulation or our codes in the UK are often put forward as best practice worldwide. The Portman Group Code has been recommended by the Better Regulation department as a good example, and the International Harm Reduction Association, for being among the top 50 best practices. We have very, very tight regulation in the UK and, by all accounts, it seems to work.

Chris Arnold: Could I add, first, that the subliminal advertising thing is a bit of a myth. It is hard enough selling stuff in your face without trying to be subliminal about it. There is this idea that subliminal works, but it doesn’t. The average consumer is getting 5,000 to 15,000 messages a day being pumped into them from every channel in every way. It is hard to be that less than 5% that cuts through and less than 0.5% that tends to get any kind of results. Subliminalism is much more of a myth. It has always been around in the ad industry and even when they did tests back in the late 1950s, which is what started exploding the myth, it proved to be pretty ineffective. The idea of just having a magazine lying on a floor and thinking that the kid is going to see it and be influenced into buying something has no evidence to prove it either.

Advertising is a lot more effective in switching brands than it is in changing behaviours. Trust me on that because, even when I worked on a lot of campaigns on sexual health and other areas, it is really difficult to change behaviour. It works much more from the bottom up when you want to change behaviour. However, what does improve behaviour more so than advertising is the media. You only have to show Beckham doing something and, I tell you, all the kids and all the adults will follow. You do it on an advert-

Q256 Dr Wollaston: If Beckham had, for example, an alcohol brand on his shirt, would that not have influence, in your view?

Chris Arnold: No, because that is sponsorship. There is a big difference to how the consumer sees being paid for and doing things naturally. If they are seen to, we know that consumers respond, but not if they think that the stars are being paid to do things. Mumsnet have just done a survey for us looking into this. One of the things that came back is about when consumers see that somebody is being "forced" to do something. If I am going to be paid to promote Coconut Water, they won’t believe it. If I naturally drink Coconut Water, which is a big trend at the moment, then people will follow suit. That is an interesting one because a lot of people are getting into this and there is no marketing for it at all. It worked from the bottom up.

Dr Wollaston: Except you have done some wonderful product placement here today.

Chair: Indeed. You will be pleased to hear we are on radio, not on television.

Professor Gilmore: I have a couple of comments about marketing and hearing that it doesn’t work. Some £800 million is spent on it by the drinks industry in the UK. There have been two recent reports, one from the European Commission and one within the UK, looking at the impact on young people. Both have come to the conclusion-proper scientific reviews-that marketing influences the age at which children take up drinking and how much they drink when they take it up.

There is a fascinating study from Stirling, from Gerard Hastings, showing, taking 9 to 11-year-olds looking at bottles of vodka with the label obscured, that 85% to 90% could identify the vodka from the shape and colour of the bottle. There is very, very early imprinting and I am afraid I am not persuaded that the marketing is not contrary to corporate social responsibility because you will know, from the last Health Select Committee on alcohol, that the Committee took sight of internal marketing documents from major drinks companies. Their internal marketing strategies did not coincide with the philosophy of not targeting young people, not encouraging excessive drinking, etcetera. Quite clearly, they were targeting young people and they were targeting excessive drinking. That has since been written up and published in the British Medical Journal.

Mark Baird: If I can touch on that point. First of all, it makes commercial sense and socially responsible sense for us to only market our products to over-18s. Under-18s are not legally able to buy our products and having products associated with under-18s tends to devalue the brand.

I would also like to touch on the piece of research that Sir Ian touched on, which was the Hastings report. It was, essentially, a longitudinal study of 13-year-olds. It was conducted in 2010 and found no association between awareness of alcohol marketing, the onset of drinking or how much the youngsters drank between the ages of 13 and 15. The study was designed to prove that alcohol marketing increases or has an effect on youngsters drinking; in fact, it proved the opposite.

Q257 Dr Wollaston: I think you will find that Professor Hastings strongly disputes that.

Mark Baird: Those are Professor Hastings’s words.1

Professor Gilmore: It is not what I heard from him, but I don’t know.

Q258 Chair: Since he has been quoted, it would be helpful if you could produce a report that demonstrates what Professor Hastings has said and we might inquire from him what he thinks.

Mark Baird: Certainly.

Q259 Rosie Cooper: I was going to ask why you spend a penny on marketing if the returns are so poor, but Professor Gilmore amply answered the questions I had. I cannot understand, Chris and Mark: if your view is such that it is not unduly affecting those youngsters under 18 and/or not encouraging people to drink, why are you doing it?

Mark Baird: If I could speak for us, we market our brands for three principal reasons. One is it maintains the integrity, credibility and image of the brand. Two, it maintains the loyalty of customers who already drink our brands. The third reason is to try and get people to switch from another brand to one of ours. For instance, our marketing on Bell’s Scotch Whisky is to try to encourage people who drink Grouse or some other brand to switch to Bell’s. We can see, by the way the alcohol market has gone over the last few years, that the market is not growing. The purpose of our brand marketing is to get people to switch from another brand to our brand.

Q260 Rosie Cooper: Can you do the link for me, then? Why would you advertise your brand on a football shirt or a rugby shirt or whatever? How does that really help you? What qualities there say, "Drink my alcohol," that is not, "Be successful. Be a winner. While you are doing it, you can do it by drinking my alcohol"?

Mark Baird: If I go to the first reason I mentioned there, it was that it maintains the credibility and image of the brand. Having your brand associated with, for instance, rugby, as we do with Guinness, that doesn’t say to people, "Drink Guinness" but it associates the brand with some of the core consumers we would expect from Guinness, which might be over-18-year-old rugby fans.

Q261 Chair: Professor Gilmore, you drew a distinction between the execution of policy and the determination of the objectives of policy. What do you think should be the objectives of public health policy concerning alcohol?

Professor Gilmore: I think the final objective is to reduce the burden of health harm and improve health and well-being. We know that that is best achieved through a population approach. Rather like talking about Sir Michael Marmot’s gradient, if you just tackle one end you make much less impact than if you tackle it at a population level and you shift the whole consumption curve down. The tool with which one can best reduce health harm is by taking a population approach to alcohol consumption, per capita consumption.

Q262 Chair: Your objective would be to reduce alcohol consumption across the population.

Professor Gilmore: Yes.

Q263 Chair: Is there a level of alcohol consumption that is-and I need to use this word carefully-in the normal meaning of the word, "safe"?

Professor Gilmore: This is one of the reasons why there has been so much controversy over safe drinking limits. The Royal Colleges produced guidance, 20 years ago, on up to 21 units a week for men and 14 units a week for women. The Government, in the mid 1990s, changed that to up to 4 units a day for men and up to 3 units a day for women. Everyone rubbed their hands and said, "Gosh, that sounds like an increase to 28 and 21." They then said, "Perhaps you should have two alcohol-free days a week."

The problem is that the risks of drinking vary by the condition. For example, the risks for getting cirrhosis are probably quite different from those for getting breast cancer. Drinking one or two drinks a week increases a woman’s chance of getting breast cancer, but for us to go around saying, "Nobody should drink at all" would begin to lose us credibility. The safe limits are an average. What we are saying is, "If you stick below these limits, you are unlikely to suffer physical, mental or social harm." That doesn’t mean to say that if you exceed them in one week a thunderbolt will necessarily come down. Nor does it mean that you are absolutely safe if you stick within those limits, and you will be increasing your risk of some conditions. It is a trade-off and a generalisation.

Q264 Chair: The reason why I asked the questions in the order that I did is that, if you want to reduce alcohol consumption across the population, the question is whether it is an objective of policy to reduce alcohol consumption in those sections of the community that are already within safe drinking guidelines.

Professor Gilmore: It is not the primary aim. What I said is that the primary aim is to reduce health harm, and we know that is most effectively done by shifting the curve down. While the primary aim is not to reduce the moderate drinker to even more moderate consumption, we know, in a public health sense, that will reduce the health burden.

Mark Baird: To touch on Professor Gilmore’s point-

Chair: I was going to bring in the other side of this argument and then come to you.

Mark Baird: -that the easiest way to reduce health harm is to reduce consumption at a population level, I should say that since 2004 consumption of alcohol in the UK has been coming down steadily. This year, for instance-the figures have just come out in May-not only is consumption down but binge drinking is down, under-age drinking is down, harmful drinking is down and hazardous drinking is down.

The unfortunate thing is that we have seen that, over that period, as consumption has come down hospital admissions have gone up. That is one of the indicators we use for health harms. What we have seen over the piece is that we have reduced the population consumption at a population level, but harms have gone up. There seems to be an inverse correlation between health harms and consumption at a population level.

Professor Gilmore: To say that there is an inverse relationship is perverse in the extreme when we have seen harm and consumption rise, pari passu, for the last 50 years. There has been a small fall-off in the last few years. It is very small compared to the huge increase there has been, and there are various factors. There probably isn’t time to go into them, but we do know that the number of people who don’t drink at all, possibly for ethnic reasons, is increasing and there may be fewer people drinking more for the rest. There do seem to be more people drinking in a harmful pattern. Clearly, the population approach versus the individual approach is not a black and white approach, but I think you will find any serious public health specialist will tell you that the population approach will give you greater benefit.

Q265 David Tredinnick: On Professor Sir Ian Gilmore’s points, do you think there is a case for making people more aware that drinking within safe limits does bring or can bring on problems such as breast cancer for women? I wondered if there was a very obvious example of a problem for men drinking within safe limits.

Professor Gilmore: I think it is a very difficult one. They have looked at this in Australia. They looked at what level of drinking would only increase your risk of dying of an alcohol-related cause by 1%. They came up with such a tiny consumption that it was laughed out of court by the general public.

We are living in the real world. We know that if a woman drinks about half a bottle of wine a week she will increase her risk of breast cancer by 10%,2 but increases it from 10% lifetime risk to 11%. Many women might take the view that, while that is a significant increase and it has been shown on a population basis, many other things in life-not least getting up in the morning-carries risks. It is a very difficult concept to get across and I, personally, have not pursued targeting people who are drinking moderately to drink less. But, as a by-product of a population approach, if you get moderate drinkers consuming a little less there will be health gains.

Mark Baird: I would like to agree with Professor Gilmore on the importance of making people aware of unit information and the weekly guidelines and bring this back to the Public Health Responsibility Deal. There are a number of things in there that will help us inform the population, such as some of the improvements we will see on alcohol labelling. There are also pledges on putting as much information as possible into on-licensed premises and off-licensed premises. The trade will make that happen.

If we also look at Drinkaware, they have done what I suggest is a terrific job over the last five years, perhaps, in making people aware of drinking limits to the point where 90% of the population are now aware that alcohol is measured in units and 75% are aware roughly of what the daily guidelines are. Those have increased significantly over the past four or five years. I think both Government and industry and Drinkaware have done an increasingly credible job of making the public aware of not only the daily drinking guidelines but also the risks associated with over-drinking.

Q266 Yvonne Fovargue: You have talked about the Public Health Responsibility Deal. How would you respond to the argument that, by signing up to that deal, you are attempting to avoid the introduction of a regulation that would damage your commercial interests-for example, a statutory minimum price per unit?

Mark Baird: It was said earlier that the industry is against regulation. We are not against regulation. Regulation has its place in areas such as drink-driving, blood alcohol limit, sales to under-18s, buying for under-18s, under-18s buying alcohol and selling alcohol to drunks. We are not against regulation. We are against regulation that seems to be unfair, ineffective or inappropriate or, more specifically, not evidence-based.

Q267 Yvonne Fovargue: What evidence have you got that it is ineffective?

Mark Baird: That what is ineffective?

Yvonne Fovargue: That statutory minimum pricing would be ineffective.

Mark Baird: There is no evidence anywhere in the world to show that minimum pricing, as proposed in the UK, would work. It has not been tried anywhere. The evidence, as it is-

Q268 Chair: Those two propositions don’t help us much, do they? If it has not been tried anywhere, there will not be any evidence.

Mark Baird: Yes, but the point I am trying to make is that the Sheffield report, which is the model used most often to defend minimum pricing, is but that-it is a model with many, many flaws. It takes no account of income so it suggests that, if a minimum price is put in, a millionaire or somebody on income support will act in exactly the same way. There is no account taken of income at all. If you look at the Sheffield report, the prediction of a minimum price of 50 pence is that an 18 to 24-year-old binge drinker will reduce their drinking by, roughly, half a pint of beer a week. I do not think anybody would agree that that is going to make much of a difference in tackling alcohol misuse. Therefore, the evidence base does not seem to be there for pricing.

Q269 Yvonne Fovargue: What commercial interests, if any, do you feel you are sacrificing in support of public health?

Mark Baird: We do not believe there is a conflict of interest between our duty to our shareholders and promoting responsibility. We want consumers to enjoy our brands, which they cannot do if they drink to excess. Our brands and our reputation are harmed if our products are misused. Our corporate reputation and our brand reputation is important to us and we realise that our commercial success and our reputational success can only be achieved in the future if we rigorously pursue a responsible drinking agenda.

Q270 Chair: Can I ask Dr Halpern if he is enjoying being in the snake-pit?

Dr Halpern: Let us be clear about a few things. The overwhelming evidence is that price affects behaviour here. It affects it generally at population level and so on. We know that from many products and we have information to suggest it would work also for alcohol.

Q271 Chair: It is hard to draw up an economic model based on the proposition that price has no effect.

Dr Halpern: Indeed. In fact, one of the things which caused some tension-remember that responsibility is an ongoing process-among some partners is that in the budget there are price changes. They are coming, in October, on super strength and also, interestingly, of course, at the lower end. Having the ruling on not selling below cost effectively creates a de facto minimum price, which you can then adjust and re-visit. You have to work fairly hard to not think that price is relevant. Of course, advertising, it is true, is primarily aimed at brands.

One of the things we would, additionally, say is that there are quite a few other things you can do and other kinds of tools that can be used, not least because of the health harms. You will remember that the harms from alcohol that follow from violence and so on-which mean you end up in A&E or whatever-are at least fourfold greater. The examples are that portion sizes are incredibly important in relation to lots of areas-so where you have a smaller glass. The interesting question there is whether, sometimes, we introduce regulations which stop us being able to have smaller portions, like the schooner arguments being in play, or whether our guidance is in the right place on the promotion of low alcohol products.

There is a lot of stuff about not just advertising in general but what, exactly, you advertise. Advertising really cut-price alcohol in relation to the retailers would be an example, and to get them to move away from cut-price promotion would be an important thing to do, although you have to work out the implication of competition law and so on. Social norms and the way in which we drink is, clearly, a big part of the story. The fact that people come together is very interesting because of the health effects of having social networks. Coming together and seeing friends and so on, as far as alcohol is part of that culture, that has positive effects. The way in which we drink and how we are consuming it via the off-tray versus the on-tray lifestyle are really important parts of the story. There are lots of other things in play, too, but of course price and advertising are part of the story.

Professor Gilmore: If I might make a comment about the Responsibility Deal and the health community, we did go along with it because, although we think information and education are not the whole answer, we felt we should give it a try. It was a new Government’s initiative. There were those around, like me, with a memory for how long there have been voluntary partnerships in the drinks industry. It was the cornerstone of the 2004 Tony Blair harm reduction strategy. There was a report by KPMG, commissioned in 2008 by the Home Office, which showed that the 10 years trying to get unit labelling by voluntary agreement had been a failure.

We understandably had some reservations about further voluntary partnerships and, when we turned up, it was clear that we were largely spectators at the party, and it seemed to be the main party in town. We felt uncomfortable with that as the evidence base was pretty slim, the pledges were already written and very difficult to change, it was co-chaired by Government and industry and it was only with a lot of effort that we managed to achieve a third co-chair from the health group.

The evidence base around the pledges was weak. It wasn’t clear at all at what point it would be said they would not be working and, if they weren’t working, whether Government would then move up the ladder of interventions. We felt, in the end, that we were in danger of being used as a figleaf of respectability to the process, so we withdrew and did not sign up to the final deal. However, we did offer, quite clearly, to stay engaged and help, behind the scenes, to set the monitoring and the independence of evaluation, which we felt would be a much more appropriate use of health professionals. That offer has not, as yet, been taken up.

Q272 Chair: You have not reacted warmly to the limited proposals that the Government have tabled for minimum pricing-not to sell at less than duty plus VAT. Why do you not regard that as at least a modest step in the right direction?

Professor Gilmore: I did say, publicly, that it was a modest step in the right direction-

Chair: I stand corrected.

Professor Gilmore: -but I said it was very modest indeed. On the positive side, it is an acknowledgement by Government that price is important, and we have heard it is acknowledged by Governments, whereas it was not some years ago. There have been significant tax increases, although we do not think tax is a very attractive way of getting a significant rise that would make a difference to the public health. The problem is, as you know and was widely quoted by The Guardian, that if you put a floor as low as duty plus VAT, you will hit one in 4,000 alcoholic beverages sold. It will not affect three litres of 7.5% white cider for £2.99 where you can get your weekly recommended limits in one bottle. That would not be hit by that floor. In principle, yes; in practice, no.

Q273 Dr Wollaston: The point is often made by Government that if we had a minimum price of 50 pence a unit it would disproportionately affect those groups on low income. Could you clarify for the Committee which groups in society are most adversely affected by the effects of alcohol?

Professor Gilmore: Notwithstanding the criticism of modelling-that modelling as done by Sheffield and there has been a Sheffield 2 since that I think is even better-it does take the evidence and make the best use of the evidence available without any axe to grind and no conflict of interest. It does show that a minimum unit price affects the heavy drinker much more than the light drinker and that heavy drinkers, whatever their income, gravitate to cheaper brands of alcohol and are more hard hit by a minimum unit price. One of the strengths of a minimum unit price is that it doesn’t affect the price of a pint of beer in a pub or a glass of wine in a restaurant at a time when pubs are closing. It is, in effect, a targeted tool.

It is said, "What about the poor moderate drinker?" We will probably be hearing, shortly, someone speaking up on behalf of the poor in this regard. The modelling suggests that the impact on the poor moderate drinker is very small indeed-pence a week. Indeed, if you look at all the advertisements for supermarkets, particularly coming up to Christmas, they are for alcohol. Alcohol is used as the hook to get people into the stores. How are they doing that? By discounting.

We published a very interesting paper in the RCP Journal, about a year ago, showing that the moderate drinker is probably paying more for their weekly grocery basket now because they are subsidising the heavy drinker. It is the heavy drinker who is coming in and buying the cheap drink and if those subsidies weren’t going on drink they might be going on fruit and vegetables-hopefully, not on any obesogenic products-on a healthy diet.

Chair: It might be going on McDonald’s.

Professor Gilmore: The argument that this would hit the poor moderate drinker really does not stack up.

Q274 Chris Skidmore: Where does the standard of proportionate universalism come into all this? I am intrigued. I am wondering if there are arguments to be made following along the lines of the Marmot inquiry. I have reservations about proportionate universalism, that we should be focusing on making the poor drink less than the rich.

Professor Gilmore: We are not focusing. We are saying it would impact on heavy drinkers across the social scale. It is not targeted at the poorest people. The impact on the less well off would be very small indeed. I know this was and is a great concern to Governments. Governments, quite rightly, have concerns about who is going to vote for them in the next election. I had vigorous debates with Alan Johnson over this, but I think he has changed his views since leaving office as to the value of a minimum unit price.

Mark Baird: I gave evidence at a House of Lords inquiry a few months back on behaviour change. Sitting alongside me was Debbie Bannigan, who is the CEO of Swanswell Addiction Centre. Her view was, for people with serious alcohol problems, price is not the pertinent issue. She said that for people who suffer most from alcohol, price is not an issue. They will avoid spending it on other things and they will turn to many different ways to get money for alcohol.

I would like to go back to what Professor Gilmore said about labelling. I have to agree that the purely voluntary arrangement on labelling was not successful, which is why we believe the Responsibility Deal offers us an opportunity to make things much better. If you look at the agreement we have now on labelling, it is a distinct commitment, it will be measured by an independent source, more than 80% of products will have that and organisations such as ours have said it will be more than 90%. What the Responsibility Deal does is not an alternative to regulation and it is not voluntary. It brings in some rigour to commitments that involve the alcohol industry, along with NGOs and others, in delivering public health outcomes and it provides a vehicle to do that in a way which can be more effective, quicker and certainly cheaper than regulation could.

Q275 Rosie Cooper: I would like to ask this of Professor Gilmore. We have heard the national regulation argument. The Government is giving a lot more power to local authorities on the public health agenda. Do you believe that they should have power to set local targets-for example, local pricing of alcohol? Do you think that would help in any way?

Professor Gilmore: Clearly, there are strong arguments for allowing local communities to have more control over their own environment and they know what their particular problems are. However, there are many examples of really good initiatives locally tackling alcohol problems, particularly in Australia with problems in some indigenous populations. The great difficulty is sustainability. It keeps going while there are some enthusiasts locally in council, or whatever, driving it through, but it is very difficult to sustain it without a national framework and without national leadership. Yes, more responsibility and more opportunity to do good things locally but, if left to local initiatives, it does not work.

I am delighted that in the councils around Greater Manchester they are talking about whether they could bring in a minimum unit price. There is a commitment and they see the health benefits. Whether that would be achievable with people driving across to the next village to buy their alcohol, I don’t know. I would support local empowerment, but it has to be seen in the context of being supported by strong national frameworks. That would include, in my view, tougher regulation about price around marketing and availability.

Q276 Chair: Would you answer, Professor Gilmore, Mark Baird’s point that, to the really hardcore alcohol abuser, price is not a significant issue?

Professor Gilmore: Clearly, if someone is physically addicted then they are much more difficult to deal with. That is why nothing is in isolation and there are the three priorities that the Alcohol Health Alliance espouses, one being around price, one being around marketing and the number one priority is around treatment services. As I may have mentioned earlier, within less than a decade, the number of addicted people has gone up from 1 million to 1.6 million in this country. For them, the issues are much more difficult. I cannot say that we know, with certainty, that their drinking habits would be influenced.

What we do know is that treatment services are very effective and cost effective. This came out very clearly from the NICE studies that were published earlier this year. Right across the spectrum, from those who are just beginning to drink a bit above recommended limits having brief interventions to the hardcore-if I could put it that way-that are often, even by health professionals, almost given up as revolving door patients. They are not. We only remember the ones that come back, but treatment services, which are incredibly patchy in this country, are very effective and cost effective where they work well.

I cannot say that a minimum unit price would halve or third consumption among alcohol-dependent people but, by God, it might well stop a few hundred thousand more from drifting into that stage of alcohol dependence.

Mark Baird: It is fair to say that price is not in the Responsibility Deal because alcohol companies are not allowed to sit together and discuss price. The Secretary of State made that very clear at the start of the process. It is not fair to say, however, that availability and advertising and marketing are not in there. If you look at one of the individual pledges which ASDA put forward, it was that they would stop putting alcohol in the foyer of the stores, which is all about availability. They have done that and delivered on that already.

There is a pledge, looking at advertising and marketing-further action-and that is specifically around introducing a sponsorship code, touched on earlier, which has been trialled, scored and seen to be successful. We would hope, in the future, that we will see a sponsorship code which will put certain things forward that industry must do if they are involved in sponsorships. On advertising, marketing and availability, there are pledges in there, within the Responsibility Deal, but it is fair to say there is nothing in there on price.

Professor Gilmore: It is also fair to say that none of the pledges in those areas brought forward by the health community were accepted. We do not accept that the ones which are in there are evidence-based and likely to have an effect and have hard outcomes that can be tested.

Dr Halpern: There was a key point about the price issue. It was kept out, as Mark said. It is genuinely a tricky issue about how to lay the negotiation without getting into trouble with the OFT. Certainly for some players, and noticeably the retailers, given how they got burnt on milk-for quite a lot-they are genuinely worried about it. Interestingly, OFT have no problem about variations in using licences at local level-going to your question-and that is a genuinely interesting area. The canny use of licensing in order to squeeze out VAT and affect the way in which people drink is interesting.

I want to challenge him a tiny bit, although I think we are 99% close. I think there are some areas which are still interesting within that envelope of the Responsibility Deal going forward. The availability thing is really interesting. It was ASDA, of course, who made that pledge, and an interesting thing to watch carefully is what the other supermarkets are doing. If a net result of this is that ASDA find they are removing the more visible products and no one else follows or takes advantage, that is a problem. It is important we celebrate what ASDA has been doing and put pressure on other players to do something similar, otherwise that does go to the core question of the flexibility of the Responsibility Deal.

Another one is the levels of alcohol within certain brand products. At least one major brand has reduced the level within one of its minor brands and some other players have been interested in it around defaults for house wines and so on. You can get a lot of alcohol out in a system where you look across the whole in that way. Again, the trickiness of doing this is sensitivity about, "Do you want to shout about the brand you have actually reduced the alcohol level in and getting that right?" It is going to be really interesting as to whether it is possible to remove alcohol in that kind of way.

Professor Gilmore: Absolutely. Can I just come back on that and say that I am not saying the Responsibility Deal should be abandoned? What we did say was we thought we were in danger of giving it a respectability without having the input into changing it. We were better on the outside than the inside, but that does not mean that it should be given up.

There are things in there that it will be interesting to watch and see whether industry is nudged in the right direction. I must say that the history of these things doesn’t fill me with great optimism. The important thing, from our point of view, is that it doesn’t allow the eye to be taken off other policies outwith the RD. I absolutely agree with you that I have never said price should be in there. It cannot be in there. But price has to be in there somewhere in the overall strategy. We must not be diverted from those by the Responsibility Deal.

Q277 Chris Skidmore: I have a point on process to address to David. Obviously, there is the Behavioural Insights Team, set up at the Cabinet Office. At the same time, you have the Department of Health focusing on social marketing. To what extent can you apply it as a Venn diagram? Do you see social marketing as being identical with whatever is being done in terms of behavioural insight or is there a danger of either duplication or in the way two departments are not working together? I noticed, in the April document that was published on Changing Behaviour, Improving Outcomes, the Department of Health is working with the Cabinet Office on piloting a payment-by-results approach in appropriate areas. I was wondering if you might be able to discuss the work that has been going on between the two Departments, conversations that have been had or whether the Cabinet Office is working entirely separately, and see where we are going with this over the next six months to a year.

Dr Halpern: Yes, of course. The Cabinet Office team is very small. It is eight, including myself, and we cover lots of areas. We cannot do every thing we would like to. Health is interesting because of its potential to do a paradigm change. We talk frequently to the Department and always agree about everything they are doing. We certainly do not see our approach as reducible only to social marketing, to be clear about this. It is part of a tool but there are lots of other things you can do.

Q278 Chris Skidmore: Sean Worth went into the Department of Health recently, didn’t he?

Dr Halpern: Yes, that is right.

Q279 Chris Skidmore: He has come from the Prime Minister’s unit.

Dr Halpern: He has, yes. That is right.

Q280 Chris Skidmore: Is Sean one of your linking contacts?

Dr Halpern: I do know Sean. We have overlapped for a long time at No. 10, although Sean is a political appointment and ours is not. Yes, Sean is, absolutely. At No. 10, in general, people are very keen. There are some very big wins. I know we are focusing on alcohol today, but, for example, around nicotine replacement there are incredibly interesting areas, which are not about social marketing but how we approach that whole area. You have absolutely enormous potential. You turn the numbers and do things around that you can do more than much of the NHS.

Q281 Chris Skidmore: Particularly on that-I know and understand you have limited resources if there is only a team of eight of you, and you have to pick and choose who you work with. In terms of the smoking cessation, you decided to work with Boots, I believe, in the paper published in December.

Dr Halpern: Yes.

Q282 Chris Skidmore: I guess that also reflects the social marketing strategy which mentions that, taking a life course through, it showed a trusted brand will deliver support on all topics that are relevant to the person at that stage. I am assuming that trusted brand might also probably be Boots as well. Generally, with things like diet and weight, you will be establishing a partnership with Lazy Town, the TV programme, which will encourage healthy behaviour in children. I know that as a result of Opposition work with the producers on the Lazy Town book. It is quite specific choosing one particular programme or one particular company in order to deliver your results. Would you hope to try and expand this? It is a slight conflict, isn’t it? You have behavioural change using specific agencies to achieve this, yet the public health agenda, from what we have heard before, in the earlier session, is obviously trying to achieve a far wider "catchment area".

Dr Halpern: One of the things we are trying to do, if you remember, is identify exemplars. You need to be able to put it into concrete to see how it works and if it will work. A good example-that comes into play in July, I think I am right in saying-is that the default will change at the DVLA on organ donation. That is a very particular example, but we think it will lead to a change from roughly 30% moving on to the register to about 70%, just using the so-called prompted choice, which is not presumed choice. That is a specific example. It does not change the entire world, but it is quite consequential and shows you the efficacy of the approach.

Boots is an example. We don’t all agree on everything; in our reading of the wider literature we were a bit more upbeat that there are ways of getting some smoking cessation which had not been fully explored, not least by getting people to commit out of their own resource, in some way, to a pot and if they manage to succeed in staying off smoking they get that back. We could wait for ages, but Boots are a very substantial company and they have quite a large reach. The alignment of their interests is more straightforward in relation to smoking than it might be for some other company so if they want to try it, absolutely. Let us work with it and make sure it is rigorously evaluated. As I said, we are quite open-minded, in some ways, about how we make this stuff work and, generally, the No.10 view is that it is an overtly pro-business Administration in lots of ways, but that does not mean that business does not have responsibilities.

Mark Baird: The phrase was used earlier that the Responsibility Deal is the only game in town. I think that is unfair-

Professor Gilmore: I didn’t say that. I said it appeared at that time there were no plans for an alcohol strategy from Government.

Mark Baird: That is the important point. We have already seen a review of taxation and pricing and we will see an alcohol strategy later on this year. The Government is doing more than just the Responsibility Deal. It is also fair to say that the Responsibility Deal is more than just nudge. Some of the pledges in there-for instance, Diageo’s pledge to fund the training of 10,000 midwives, which, unfortunately, received some unfair criticism last week-are much further than nudge. That is making a real different to the future of many unborn children in the UK. There are many more things within the Responsibility Deal. Let us remember that it is only six months old and, in fact, it has only been announced two months ago. There is a lot more to come. Whereas nudge is behind the theory of the Responsibility Deal, there will be many things in there which will make a discernible difference to alcohol misuse.

Q283 Dr Wollaston: It is an interesting discussion to be had there as to whether Diageo, which I think includes vodka in its range, having a brand which has been widely taken up by young women, now-having spent some time marketing these brands to young women-is in a position where you are part-funding midwives to tell them not to drink it when they are pregnant. You could say you would be better not to market to young women in the first place, wouldn’t you?

Mark Baird: The difference you are making is that we are not marketing to pregnant young women. What we are doing is funding a programme to allow midwives to get the messages across to pregnant women that drinking is not a sensible thing to do while pregnant. Trying to link that to the marketing of vodka, I don’t think, is fair. I don’t think the two come together.

Q284 Dr Wollaston: You don’t think there has been an increase in the levels of vodka consumption by young women over the last decade?

Mark Baird: Yes, there has been.

Q285 Dr Sarah Wollaston: There has been. That is partly as a result of marketing, presumably.

Mark Baird: Partly, yes. I still don’t see the link to warning pregnant women about the dangers of alcohol misuse and why it is wrong for an alcohol company to fund that when the alcohol company has not been involved in the development, design or delivery of that programme. What we are doing is funding a programme which probably would not-in fact, almost certainly would not-have been funded. That funding would not have been there. As part of the Responsibility Deal, it has forced us to go further. We have taken up a successful pilot that trained 500 midwives over the past two years and 94% of those 500 midwives have said that they believe this particular training should be given as part of midwives’ general training.

Q286 Dr Wollaston: I get all that. If you were really looking at social responsibility, wouldn’t it be better not to be heavily marketing vodka to young women in the first place? To give you an example, I was sent an e-mail this week from somebody who went to see a 12-certificate film, and there were no fewer than four very heavy and very effective alcohol marketing advertisements. That was before a 12-certificate film. Is that responsible?

Mark Baird: Cinema advertising, like all advertising, has to conform to the CAP Code such that 75% of the audience who will see that film are generally over the age of 18.

Q287 Dr Wollaston: A 12-certificate film?

Mark Baird: The regulations which apply also apply to the cinema. The regulations are there and they are there for a reason. It is controlled by the Cinema Advertising Association and it is done in conjunction with a panel. They look at films and decide which films it is appropriate to advertise alcohol within. Again, it is tightly regulated, as it is on TV and as it is on all forms of advertising within the UK.

Chris Arnold: I am surprised to hear that. I think that isn’t an issue about advertising. That is an issue to do with why those were running during those shows. That may have been a miscalculation. Generally, you would not get that running. The regulations we have to abide by are so strict within our industry. We are not allowed to do certain things and we are not allowed to say certain things. That is why most brands spend the time trying to move from one brand to another rather than trying to increase the market. It is too expensive to do that.

Q288 Dr Wollaston: Would it not be more effective just to advertise in cinemas at over-18 certificate films rather than 12-certificate films?

Chris Arnold: The way the cinemas put the ads up is that they were only running that and I am a bit surprised when you tell me there is a 12-certificate film running lots of booze ads because-

Dr Wollaston: There were four.

Chris Arnold: That is not actually an issue for the industry. That is an issue as to why they were running those and whether somebody had made a miscalculation or not. I don’t think that is something you would find happening regularly. I have certainly never seen it before, taking my kids to the cinema.

Professor Gilmore: I have had examples sent to me of 12-certificate films clearly aimed at young people. The Dark Night was one of them where there were several alcohol adverts before the film was shown.

Dr Wollaston: Thank you.

Chair: At that point, we are beyond our witching hour. Thank you very much for coming and thank you for a spirited debate. We shall reflect and try to draw some conclusions.