To be published as HC 1048-iv

House of COMMONS



Health Committee


Tuesday 12 July 2011

Professor Dame Sally C Davies DBE, Anita Marsland MBE, Professor David R Harper CBE and Professor John Newton

Professor Alan Maryon-Davis and Dr Gabriel Scally

Evidence heard in Public Questions 289 - 409



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Oral Evidence

Taken before the Health Committee

on Tuesday 12 July 2011

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Dr Daniel Poulter

Mr Virendra Sharma

David Tredinnick

Valerie Vaz


Examination of Witnesses

Witnesses: Professor Dame Sally C Davies DBE, Chief Medical Officer, Department of Health, Anita Marsland MBE, Transition Managing Director, Public Health England, Department of Health, Professor David R Harper CBE, Director General, Health Improvement and Protection, Department of Health, and Professor John Newton, Chair, Department of Health Working Group on Information and Intelligence for Public Health, South Central Strategic Health Authority, gave evidence.

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

Could I begin by asking you to introduce yourselves and the particular areas of departmental responsibility that you come from?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chair: Go on, yes.

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

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

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

Q296 Chair: Not necessarily speaking truth in private.

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

Chair: That is not what I meant.

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

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

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

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

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

Do you want to pick up on the links across?

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

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

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

Valerie Vaz: Yes.

Anita Marsland: It is jointly appointed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q306 Rosie Cooper: With no money.

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

Profe ssor Davies: They are going to have a budget.

Oh, dear, you kind of interrupted me.

Rosie Cooper: I am sorry.

Chair: Savings, integration, local government. 

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

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

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

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

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

Professor Davies: Can you talk about the pathfinders?

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

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

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

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

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

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

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

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

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

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

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

Professor Davies: Do you mean at the appointments committee?

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

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

Q312 David Tredinnick: Fine. Fair enough.

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

David Tredinnick: Thank you.

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

Q313 Chair: It is a dual key.

Professor Davies: Yes.

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

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

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

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

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

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

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

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

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

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

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

Q319 Valerie Vaz: Will there be jobs for them?

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

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

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

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

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

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

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

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

Professor Davies: I am responsible for public health.

Q323 Rosie Cooper: They are assured of jobs.

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

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

Anita Marsland: Maybe a slight-

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

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

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

Chair: Thank you.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Professor Davies: Could John come in?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Professor Harper: The general principle that I know you will be very familiar with is that front-line services, as far as possible, are protected. As far as the rest of the administration is concerned, the whole system is subject, over the next three-year period, 201415, to a cut of the order of a third. That will apply equally-

Q337 Rosie Cooper: Except to trainees.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rosie Cooper: Thank you.

Q349 Mr Sharma: There seems to be some confusion about the extent to which funding for Public Health Observatories has been cut in 201112. In an Adjournment debate on 17 May 2011, the Public Health Minister referred to "The Government’s contribution of £12 million to the observatories". Can you explain to us what changes have been made to the observatories budget this year and exactly how that £12 million figure was arrived at?

Professor Newton: I will come in there, Chairman, if I may. I should say, by the way, that I spoke to the secretariat and it might be helpful if I give you a written comment as well, since there are figures involved, but I can briefly explain now as well.

If I take the overall approach to the funding first, in recent years the Public Health Observatories have received two types of funding from the Department of Health. The first is a core grant to support reasonable health intelligence infrastructure and the second is funding to support specific programmes of work-specific projects, such as the health profiles or the specialist observatories, and many of the other things that you will be familiar with. In 201011 these were, respectively, £5.1 million for the infrastructure and £7 million for the specific projects, the specialist observatories. That totals £12 million. That was for last year. I can give you the list of what made up the £7 million.

In this year, 201112, the budget committed by the Department to health intelligence infrastructure is the same-£6.5 million-as it was last year. As last year, that budget will be used to support the Public Health Observatories but also to deliver some other public health intelligence functions, such as congenital anomaly registers and health impact assessment gateway projects. It is not only for the Public Health Observatories, but it is there for the Public Health Observatories and it is the same as last year. This year, however, we have asked the Public Health Observatories to work more in an integrated national approach. In fact, in different roles, I have been having that conversation with them for the last two to three years and there was widespread acceptance that the Public Health Observatories should be moving to a national structure. This recognises the change or move away from regions themselves, but particularly regional public health programmes that are not now funded. The requirement, and in fact the experience, is that the observatories have worked extremely well when they have taken national leader roles, things like the specialist observatories.

What we have asked them to do is develop a single integrated work plan and Professor Brian Ferguson, when he was here, indicated that he was working on that. He has been working on it for a year. We asked him for it, in fact, in March this year because we wanted to base this year’s funding on it. He has told me that it will be ready by the end of July. While we are waiting for that programme, we have allocated £4 million to the observatories for this year for the infrastructure function. It is an unspecified amount upfront to the observatories which they have-guaranteed-for the whole year. If, when we have received it, the plan requires more than that for the observatories to deliver it, the budget is available to fund the plan.

We think the move to a national integrated approach will be efficient. For example, each observatory currently supports their own website. In addition, there is APHO’s website. That is 10 websites pointing people to largely similar resources, so we think there are efficiencies from this single integrated work plan. However, I stress that the budget remains the same and it is available to support the observatories if they need it. We are obviously reluctant to support a model that is going to be left slightly out of date by all the other changes happening across the public health system.

In terms of the rest of the money, in other words, the specific projects, the specialist observatories and so on, that is business as usual as far as the Department is concerned. The figure, so far, is that £5.2 million has been confirmed for this year. I should say, by the way, that the £4 million confirmed for this year already would represent a reduction of 23% in the core budget if they receive no more money for the rest of the year. Obviously, if they do receive more money as the year goes down, that reduction would be less than 23%.

In terms of the special projects, the reduction is, as it happens, also equivalent to 23% compared to last year. Some of that is because programmes have come to an end; they were threeyear programmes that have reached their end. Some projects have moved; for example, the National Library for Public Health has moved to NICE. The same work is being done but not through the Public Health Observatories, so there is a reduction in the money going to the observatories.

Going back to the original figures, the money that I have mentioned is the money the observatories get from the Department of Health. In addition, in 201011, the observatories received £3.7 million from other Government Departments and from other sources such as the NHS Information Centre, making up their total budget.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Examination of Witnesses

Witnesses: Professor Alan Maryon-Davis, Honorary Professor of Public Health, King’s College London, and Dr Gabriel Scally, South West Regional Director, Public Health, South West Strategic Health Authority, gave evidence.

Q356 Chair: Thank you very much for joining us this morning and for sitting patiently through that last evidence session. Could I ask you both to begin by introducing yourselves and your background of interest to these issues?

Dr Scally: Certainly, and thank you, Chairman. My name is Gabriel Scally. I am Regional Director of Public Health for the South West Region. I have been a regional director of public health in England since 1993. In that role, I am employed by the Department of Health, so I am a civil servant, but I am also a director of the Strategic Health Authority for the South West. In the context of what we may be talking about in terms of regulation, I should mention that I have also been a member of the GMC for 10 years.

Professor Maryon-Davis: Good afternoon. My name is Alan MaryonDavis. I am a public health doctor. I have a background in hospital medicine and general practice, but I have been a public health doctor for over 37 years now, including being a director of public health for an inner city borough in south London. I am also the immediate past president of the Faculty of Public Health, which is the professional body for public health specialists. My role today is to provide a broad overview.

Q357 Chair: Thank you very much. We shall no doubt need that. I would like to begin by asking Dr Scally to talk about the background to the work you did on recommendations on professional regulation. What was the remit you were given and the background to the report that you produced? To what extent were you pointed in a direction, or did you feel there was a sense of preference of what the outcome was likely to be?

Dr Scally: I was asked by Sir Liam Donaldson-the former Chief Medical Officer-who was acting in consort with his three CMO colleagues from the other countries of the UK, to undertake this review because there was a general feeling in the public health profession that the current system of statutory regulation was not adequate. My task was to look at the systems and come up with some recommendations, whether they were a continuation of the existing system or proposals for change. I duly reported back to the CMO-by that time, it was Dame Sally Davies-and then my report was published alongside the White Paper for consultation in the autumn.

Q358 Chair: In summary, what were the inadequacies of the current system that led to the establishment of your process?

Dr Scally: It had been a view from the early days of multidisciplinary public health that there should be a statutory regulatory framework. However, as part of the move towards multidisciplinary public health, a voluntary register was established. Indeed, that is one of the steps that the Government prefers to see in terms of a move towards regulation of a profession-or, in this case, a branch of a profession-but it was always envisaged that it would move to a statutory footing. That had not happened. The existing system was continuing and was operating, but not in complete consort with the rest of the regulatory system consisting of the GMC and the GDC. There were a number of routes of entry to the voluntary register of the GDC and the GMC and this was causing unnecessary confusion.

Q359 Chair: Was there any evidence that it was leading to prejudices to public safety?

Dr Scally: I am unaware of that, but there have been concerns that the routes were unequal. Some younger professionals seeking to come into public health were choosing to aim for the voluntary register route rather than going through training and qualification because they had a feeling that it was somehow easier and less demanding than going through proper training.

Q360 Chair: Is that a coded way of saying it was easier to get into public health through the nonmedical route?

Dr Scally: No. The examination and the structured training route is open to medics and nonmedics. Indeed, increasingly, the balance of people going through that route is evening up, if not tipping in favour of nonmedics going through the formal training route. It was certainly a view that we needed to look at the whole system and get it much more unified so that there was one route everyone could rely upon to produce highly skilled, highly qualified and regulated public health professionals throughout the country.

Q361 Chair: To be clear, it was your recommendation that there should be a clear pathway to a full, single compulsory regulatory framework?

Dr Scally: I had several recommendations, but to summarise them, the three key ones were, first, that there should be a system of statutory regulation that covered all senior public health professionals-of course, about 80% are doctors or dentists and already covered by statutory regulation-and it should be a universal system of statutory regulation; secondly, that there should be protection of title, that the term "director of public health" or "consultant of public health" should be protected and only able to be occupied by someone who was on a statutory register and the third thing was that I recommended there should be a single predominant pathway to registration, which would be through qualification, structured training and doing the examinations of the Faculty of Public Health. I very much saw the Faculty of Public Health coming to occupy a very central place in the validation of training and training programmes.

Q362 Chair: How do you think those recommendations would change the balance between the medical and nonmedical routes? Would that lead to a process of change in what it meant to be a public health doctor, or indeed a director of public health?

Dr Scally: No, I don’t think so. I do not think there would be any detriment to that. Indeed, my view was that it would provide reassurance that all senior public health professions were trained, qualified and regulated to a satisfactory degree. Indeed, having looked at various schemes of regulation for health care professionals, I found that the closest analogy was with the pathologists, where approximately 20% of pathologists occupying consultant posts are nonmedical; the medical component of pathology is regulated by the GMC and the nonmedical regulated by the Health Professions Council. That was my specific recommendation. That would put us very much on a par with pathologists and provide a very good basis for going forward, particularly, should I say, into an era when senior public health people-of course, the White Paper on public health appeared subsequent to my report-will be employed by local government, perhaps by the NHS Commissioning Board, by the Department of Health via Public Health England and, indeed, in academia. Therefore, one standard statutory regulatory framework, I thought, would fit very well with that.

Q363 Chair: I understand the point about reassurance. I was asking a slightly different question, which is whether you thought the adoption of that framework, as you recommend it, would, as a matter of practical predictive effect, lead to a change in the nature of the public health profession.

Dr Scally: No, I do not think so. All the evidence from our recruitment to the structured training programmes is that we have a good balance between medical and nonmedical entrants and a good balance of completion of that programme, and people are coming on to both the statutory registers at the moment and, indeed, the current voluntary register perfectly satisfactorily through that structure. There is usually a five-year training programme involving the examinations of the Faculty of Public Health.

Q364 Chair: You do not see any particular reason to change that balance, nor do you think that your recommendations would lead to a change in that balance.

Dr Scally: No, indeed.

Q365 Chair: Neither an intended or unintended effect.

Dr Scally: No. I cannot envisage that it would. It operates perfectly satisfactorily in terms of recruitment into the profession at the moment.

Q366 Chair: Professor MaryonDavis, you were going to offer us independent or balanced advice.

Professor Maryon-Davis: What is more likely to change the balance of the public health profession in terms of medical or nonmedical, which I think is what you were getting at, are the new structures that are being put in place under the current system in England; we are not talking about other parts of the UK. That is going to have a much more profound effect on the rebalancing because a large chunk of public health specialists will be working in local authorities, as we know, and that is a kind of alien setup for public health specialists up till now. That may have the effect of deterring some doctors who would have gone into public health from joining because they may feel that they are moving away from the National Health Service and into this slightly alien territory they are not used to. I think the nonmedics will find it much more comfortable working in that sort of setup. The medical members will tend to move towards the health protection function of Public Health England and, also, the health care public health function you mentioned earlier on-advising on the needs assessments and evaluating services or service reconfiguration. Therefore, we will start to see a bit of a split in terms of the professional background of public health specialists.

Is that a good or a bad thing? It is hard to say. It should be a good thing as long as there is crosstalk between the different groups. As long as there are good communications across the commissioners, Public Health England and the local authorities, in particular, and hopefully with academia as well, and the information side of things, and there is a continuing critical mass, as it were, and people support each other, that could work okay. Otherwise, there are dangers in fragmentation.

Q367 Chair: I was quite struck, in Dr Scally’s response, that there was neither an intended nor a predicted unintended consequence in terms of changing the balance. This is a pretty profound change that is being proposed. I am surprised that it is neither motivated by, nor anticipated to produce, a change in the balance.

Dr Scally: Chairman, I may have misunderstood your question. I understood your question in terms of my recommendations around regulation. If you are asking me a different question, which is about the overall effect of the public health changes, I agree with Professor MaryonDavis that there is that possibility. However, as I think perhaps you mentioned earlier, these changes, in so far as they affect public health practice locally, are very much public health coming home.

Neither Alan or myself are probably venerable enough to have worked in the local authority setting-I was a medical student at the time-but you have to remember that there is a long tradition, going back to 1848, of medical officers of health working very successfully within local government. Of course, they operated against a background of protection, in terms of their independence, the inability to sack a medical officer of health without the agreement of the Ministry of Health, a requirement that they should be properly qualified and possess a diploma in public health and that every local authority above a certain population size had to have a medical officer of health. There was a very rigorous system. The good name of medical officers of health ensured that there was a steady flow of medical graduates into public health at that time and that is very much what I hope we will manage to establish in terms of the position and operation of directors of public health at a local level.

Professor Maryon-Davis: May I add to that? Because of these changes and because directors of public health, but also consultants in health protection and other members of the team, are going to be, in the future, in such crucially important roles for the health of their population-they will have responsibility for delivering on various health programmes-it is absolutely vital that they have statutory regulation as described. It is very much an issue of public safety. That is at the very root of it all. You only have to look at what has happened in Germany just recently with E.coli. There have been over 100 deaths there. That could so easily happen in this country.

The directors of public health have a crucial role and responsibility for coordinating the response to that sort of outbreak, working with Public Health England. Pandemic flu could hit us again at any moment. God forbid that it happens in the next couple of years while we are in disarray, but it could happen. Again, there is a crucial responsibility. There is cancer screening. I was always very worried when I was a director of public health about cervical cancer screening, about the wrong letters going to women telling them they are okay when they are not okay and that sort of thing. It could easily happen and there would be massive consequences.

Q368 Chair: It has happened.

Professor Maryon-Davis: Indeed. Emergency responses and immunisation are crucially important things which have a direct effect on the health, life and limb of the general public. There is also the role in communicating with the general public, which can go horribly wrong. To my mind, it is absolutely crucial that not only directors of public health but also public health specialists in general enjoy the same statutory regulation as the medics and the dental people. It should be an equivalence. The trends in recruitment are now that there is a preponderance of nonmedics coming into the specialty. In fact, the latest figures are 2:1. Therefore, if you look to see that cohort coming through, it is going to play out in terms of the people on the ground.

We must not have a "postcode" public health system. We have to have equivalence across, parity across and we have to have employers, who will be largely local authorities but others as well, confident that they are employing people who are quality assured and are fit and proper-to use the current phrase-to act in those positions of responsibility.

Q369 Chair: David wants to come in, but I want to come back to this question of balance. The figure you gave of a preponderance of nonmedics coming into public health is a striking piece of evidence against the background of this having been originally a medical qualification. Do you still say that we should be virtually blind to the proportion of medics and nonmedics?

Professor Maryon-Davis: I am blind to that, but, in terms of the current debate about regulation, it is important to point out that difference.

Q370 Chair: It is important to point it out but then to be blind to its consequences.

Professor Maryon-Davis: Providing that people who are in those positions are quality assured through a robust system of statutory regulation with the full force of the law behind it, which is the big difference about the statutory regulation, the employers can take comfort from that and so can the public.

Q371 Chair: One more go and then I will shut up. It surely goes to the culture of what it means to be engaged as a public health professional if we are moving into a world where less than half, and potentially significantly less than half of them, are medically qualified.

Dr Scally: How this will play out remains to be seen. I know, in my own region in the south-west, that we have recently recruited five trainees and none of them are medical. This is the first time in my very long experience that that has been the situation. Public health has moved to incorporate people from a wide range of professional backgrounds, and that has been greatly to its advantage, but in my view, public health would be weakened unless there was a substantial proportion of people from a medical background working within it because of the nature of much of the work that we do. Many of the things that will stop that happening lie around the way in which the new public health system is set up in terms of some of the issues that you have addressed, in terms of the status of the director of public health and of consultants within local authorities and young people in medicine seeing public health as an attractive career option for them.

Q372 Chair: One of the issues that the Committee is interested in-way outside this current public health inquiry-is the role of professional regulators through the GMC, the NMC and those bodies. I would have thought it merits further thought-I put it no more provocatively than that-that a new strategy regulatory structure should be established that would be blind to the balance between medical and nonmedical input into a new regulatory body or recruits into the work force.

Dr Scally: I certainly think, as a system, we should not be blind to it. It lies within the realm of developing a work force plan for public health for the future rather than in relation to regulation, if I may say so.

Q373 Chair: Surely the regulator has to own the concept of quality-what it means to be a professional-in that particular profession. If the regulator does not own that concept, who does?

Dr Scally: If I can go back to my analogy with the pathologists, the organisation that holds that role is the Royal College of Pathologists, and I very much see the Faculty of Public Health holding that role with regard to quality and advising the regulators as to who should be admitted to the particular register that they operate.

Professor Maryon-Davis: A lot will depend on what jobs are out there. Where there are jobs for public health people to advise on commissioning and to advise on the commissioning of clinical services, there is clearly a role for somebody who comes from a clinical background-medical, nursing or an allied health professional. If there are jobs out there to advise on outbreaks of flu or other things, there is a strong clinical or medical element, so that is another one. Employers will play a big part in this in specifying the sort of public health person they may want for a particular job.

Q374 Rosie Cooper: I am flying a kite here really, but listening to you, would a local authority be more likely to appoint a doctor to a public health role or a nonmedic, in that they would more likely fit in with local authority practices or ways of working?

Chair: Habits of thought.

Professor Maryon-Davis: It is an interesting thought, if one speculates. A key point in this is pay. Most of us in public health are fighting to make sure that the nonmedics and the medics are at the same pay level so that the issue of the cost of employing that person does not come into that kind of judgment.

Dr Scally: From my own experience in the south-west, we have 14 directors of public health, 13 of whom are joint appointees between the local authority and the local primary care trust. Having sat through a very large number of appointment panels, the choice, as you have put it, has never been a key deciding factor. It has been who has been the best person for the job, though there is a view among some local authority people that they would prefer a medically qualified person to undertake that role.

Q375 Rosie Cooper: I share that thinking, but I am looking forward. Times are going to be very, very difficult and there may be a view that an independentthinking medic may be more difficult than a public health professional who was more used to the ways of business or local authority working. The choices may just be different.

Dr Scally: Most of the people who are nonmedical but within the public health fraternity tend to come from some form of healthrelated background. It is very interesting because it is not, by any manner of means, the medically qualified public health people who are less involved in issues such as the effects of transport on health or housing on health-not at all. There is, of course, that very long tradition of public health people caring passionately about the social determinants of health, and that does not divide, in my long experience, necessarily along medical and nonmedical grounds.

Q376 Rosie Cooper: But in the future they will be making those choices inside a local authority.

Dr Scally: Chairman, if I may say so, in terms of how I choose to spend my time and energy as a regional director of public health, it is orientated very little on the clinical side of the business, except when it goes wrong, in which case I am called upon to sort things out. It is very much about the determinants of health around smoking, diet, physical activity, transport policies in the south-west, for example, or housing policies and what kind of urban extensions we want to build to house the increasing population. All those areas are absolutely core to my personal practice.

Q377 Mr Sharma: My question is about registration. If registration of nonmedical public health specialists is to continue to be voluntary, as the Government proposes, what are the options regarding who should maintain the register and which do you favour?

Dr Scally: Chairman, I have made my recommendation to the Department and the Department is currently contemplating these issues. The current Government position is that regulation should be commensurate to risk, that there is a presumption in favour of voluntary regulation and that more discussion is needed on these questions. I have made my recommendations and I think there is a role in future in terms of the public health work force, for example, for the Royal Society for Public Health and the use of its charter in terms of potential regulation of public health practitioners. Beyond that, I am unable to go.

Professor Maryon-Davis: I would agree. I have argued very strongly for statutory regulation of public health specialists, who are the senior ones. There is a role, potentially, for voluntary registration or regulatory registration of people at public health practitioner level, which is the intermediate level. There are some good reasons for that and it would seem to fit quite well. In that respect, I could see either the current voluntary register taking on that role or the Health Professions Council. There are various models, but that is for practitioners, which is the intermediate level of public health. For the senior people, the public health specialists, as I have argued very strongly, we should have statutory regulation. My concern is that dogma is ruling common sense here at the expense of public safety, which is really the issue.

Q378 Mr Sharma: The Council for Healthcare Regulatory Excellence has argued that it should have the statutory power to recommend a professional group for statutory regulation in the interests of public protection. How much merit would that approach have?

Dr Scally: That is a perfectly valid approach. There is a difference in respect of public health in that about 75% or 80% of current senior public health professionals are currently already subject to statutory regulation, so we are not a professional group coming de novo to the issue of regulation. My report was making the suggestion that that should become 100% of the public health profession, subject to statutory regulation.

Professor Maryon-Davis: To extend the regulation to the nonmedics is simply an extension of the statutory regulation, of the current setup. It would not require huge amounts of legislation to put through. It is a step which I think is important to take.

Q379 Chair: You said, in your previous answer, that you favoured doing it because you felt the public were at risk if it was not done. That harks back to an earlier question I asked Dr Scally, whether there is evidence of risk to the public arising as a result of the nonregistered status of nonmedics.

Professor Maryon-Davis: Yes. The public needs assurance, and needs to take comfort from the fact that the people who are in charge of the health of the population are fit and proper. Employers need that assurance too. Indeed, if you are employed by Public Health in England, the Secretary of State could do with a bit of assurance.

Q380 Chair: The desirability of assurance is a different thing from evidence of risk of the current position, is it not?

Professor Maryon-Davis: Gabriel will probably be able to answer this better than I can. The risks in the current system are that if, for some reason, the checks, balances and assurances are not there and if there are people who are employed who do not fit the system, that could put the public and the employers at risk, specifically around the issues I mentioned, which were outbreaks of disease, cancer screening and immunisation, where there are decisions that are made by people in positions of responsibility that can affect the lives of literally thousands of people. There could be a communications breakdown, which, again, could affect the lives of these people. The potential risks are huge. It could be tabloid stuff. It could happen tomorrow and it does happen, as you said earlier on. That is a worry. There needs to be a strong system which provides the sort of assurance that we are talking about. There are risks in there which could be alleviated by having a statutory system where the force of law comes into play in dealing with any issues that arise in terms of falling down on the job, basically.

Dr Scally: I think there is considerable risk. I look back at my own professional career and some of the decisions I have been involved in and taken around, for example, intervening to stop paediatric cardiac surgery in Bristol or on several screening issues, or even things like the siting of pyres and burial pits for animal carcases during the footandmouth outbreak. Always at the back of that was that if I made the wrong call on those I would be held to account professionally. That was because a requirement of my post was that I was a registered medical practitioner.

One of my fears about the use of voluntary registers is that they are just that, and someone can leave them. This is indeed a problem, I remember, that we confronted in the GMC. When someone got into trouble in the medical profession they merely resigned from the GMC and could go off and practise perhaps somewhere else in the world or in another jurisdiction. The Government’s position on voluntary registration is quite clear. The White Paper in February this year, a Command Paper, stated that: "No staff will be compelled to join these registers and employers will not be required to employ staff from these registers, though they could choose to do so."

It is not just an issue of the assurance of standards, to make sure the right decisions are made in some crucial circumstances; it is also a matter of maintaining those standards so that if people transgress, for whatever reason, we have an ability to ensure that their future practice is moderated or modified in some way.

Q381 Chair: Going back to this question of the twin routes into public health, you still propose that two lists are maintained in one register.

Dr Scally: My preference would have been to be able to convince the General Medical Council to take on all of public health, but they were reluctant to do so. They felt they had enough on their plate with revalidation and various other changes in the GMC. That would have been my preference. Having looked at all the options, however, as I think I said earlier, the closest analogy I could find was with the pathologists where the medically qualified pathologists were registered and regulated with the GMC and the nonmedical pathologists by the Health Professions Council. That seemed to me the best way forward and is indeed what I recommended.

Q382 Chair: Professor MaryonDavis referred to the grades of specialist practitioner, and there is a third one.

Professor Maryon-Davis: It is the wider public health work force-health visitors, GPs and a whole bunch of people who do public health. They would not see themselves as necessarily public health people per se.

Q383 Chair: No. One of the surprises I had when I was reading some of the material for this session was that a health visitor is regarded as part of public health. That is another debate. Could you characterise for the Committee the nature of the work that the specialist and practitioner grades do and the implications of those classifications?

Professor Maryon-Davis: The specialists, who have either been through a five-year training programme on top of their basic professional background or who have presented a portfolio, are experienced people and they have presented their experience and been accepted on the basis of that; they tend to be senior people in positions of considerable responsibility. They are either in strategic positions, like directors of public health, or responsible for specific areas such as health protection, for instance, or it might be around health improvement-the three main domains-but they will be in positions where they are dealing with senior people in the hospital sector, in a local authority or in other areas depending on who their employer is. Basically, they are working at a senior level, making big decisions. They might be in command of quite large budgets and so on and so forth. The practitioners tend to be people who are at an intermediate level, such as health promotion officers or specialists, people working in informatics, people working in health protection but at a lower level, and specialists. What other sorts are there, Gabriel?

Q384 Chair: It is very unlikely somebody would be a qualified doctor and a practitioner.

Professor Maryon-Davis: It is pretty unlikely.

Dr Scally: It is unlikely but not unknown. We should not try too much to demarcate the boundaries here. It is quite clear at the high level of the profession-consultant level, directors of public health level-that those people are highly specialised and work solely within the public health realm. When you get beyond that, the boundaries are more blurred, and I think correctly so. I would like there to be public health people-people who think of themselves as contributing to the public health-within the transport or housing departments. Indeed, in my region, we put a lot of money recently into making it possible for people from local government to undertake a certificate, diploma or masters in public health to increase their skills. I firmly believe that we need a spread of public health knowledge and interest across the whole of the public sector.

Q385 Chair: I understand that thought process, but it is, to some degree, in conflict, is it not, with a desire to create a status for public health as an identified regulated profession with all the obligations that go with professional status?

Dr Scally: There is territory to be worked on, particularly around people such as health visitors who have their own regulatory body and framework. As I say, it is no easy demarcation. The demarcation that my report was particularly concerned about was the people who are occupying the specialist professional roles, and it is much clearer there.

Q386 Chair: Your advocacy of compulsory regulation is focused on the specialists, not on the practitioners.

Dr Scally: Indeed, that was the nature of my review and its recommendations.

Q387 David Tredinnick: I want to move on to public health work force strategy. The White Paper of November 2010 sets out the Government’s vision for the public health work force: "it will be known for its expertise, professionalism, commitment to the population’s health and wellbeing and flexibility." Dr Scally, in your report you concluded that "there should be, as far as possible and allowing for dental public health, a single training pathway for specialist training in public health". I know we have touched on some of this before. How is this aspiration affected by the proposed new structure of the public health services?

Dr Scally: I do not think the aspiration is affected at all. What we will have to do in public health is look at the competencies that are required of people who go through that training programme. Quite clearly, particularly with the move to local government, there is a requirement for an expanded or a different skill set. I only have to think of the challenges of dealing with local government councillors and the move from directors of public health being an executive board member of a primary care trust to being an adviser to elected members and to a cabinet to see that that is quite a considerable difference and quite a considerable skill set required of people. There will have to be a look at the content of the training, but our training framework is a good, sound one, which indeed is one of the requirements for statutory regulation.

Q388 David Tredinnick: Thank you. What dangers do you see in the cohesion of the public health service work force in the proposed new system?

Dr Scally: I am not sure-

Q389 David Tredinnick: You have a public health work force and we are coming up with a new system. How far could dangers of a lack of cohesion be mitigated by Public Health England taking on the entire work force, for example, and then seconding it out to local authorities and NHS commissioners?

Professor Maryon-Davis: Do you mean dangerous to the cohesion of the profession?

Q390 David Tredinnick: I mean that the cohesion of the public health work force is important. I want to know how, in the new improved system, this is going to work and whether there will be the cohesion that is desirable or whether it will be fragmented. There have been some issues raised, some of which-

Dr Scally: I can see the issue. The biggest threat to cohesion is through the loss of senior people as we go through a restructuring or liberation. I am in my seventh incarnation as a regional director of public health, so I have been through more than my fair share of these. In every serious restructuring affecting public health at a local level, we have lost anything up to 30% of the senior people. I think that is our biggest single threat. There is no sign of that happening at the moment. People are responding.

Professor Maryon-Davis: I would disagree with that.

Dr Scally: Maybe it is just in my region. The Government’s position is that directors of public health and their senior colleagues will be employed by local authorities and that Public Health England will be involved in the appointment process. I know that some public health organisations are advocating that they should all be employed by Public Health England and then seconded in.

Personally, and I must give my personal view here, it would be not good for public health if all directors of public health were employed by the Department of Health and were all part of the one organisation. It strikes me that that would not be a healthy situation in terms of their independence, freedom of thought and practice. Therefore, I would strongly support that the employment should be with local government. When you look at the coherence of the medical officers of health and the power that they held as a group within the country when they acted collectively, they were very coherent indeed.

Q391 David Tredinnick: Do you mean before 1974?

Dr Scally: Pre-1974, yes, indeed.

Professor Maryon-Davis: I am certainly in favour of directors of public health being employed by local authorities. That is the legitimate locus for them, but I think the links with Public Health England have to be pretty strong and, as I mentioned before, the links with the commissioners have to be pretty strong.

Q392 David Tredinnick: The Royal Society for Public Health has told us: "Local government has little experience of the expectations and responsibilities associated with medical/public health training, or of working with postgraduate Deaneries." Do you think that is a legitimate concern and if so, what shall we do about it?

Professor Maryon-Davis: That is a concern. If you are talking about the training, there are risks in what I would regard almost as the atomisation of public health, going in different directions: local authorities, Public Health England, commissioning, private sector or wherever. There are issues there. Local government currently does not have the mindset and is not set up, as it were, to understand the training programmes. That can be learnt and that can be acquired and I am sure it is a barrier that can be got around, but at the moment it is a bit of a risk and will need to be addressed. What is important is that trainees coming through the system must be given the opportunity to have experience in a variety of settings so that they build up a broad view of the range of public health.

Q393 David Tredinnick: Thank you. Is there a danger then that in the absence of statutory regulation, the public health work force within local government could become professionally "diluted"? Should councils be obliged only to take on appropriately qualified and experienced staff?

Professor Maryon-Davis: Yes. On that basis, they certainly should. That is something which I would hope this Committee could make a strong recommendation about because that is a considerable risk in terms of the effectiveness of public health.

Dr Scally: We have to remember that what is envisaged in the transition, and the reason for directors of public health managing the transition, is that public health teams will simply move from their current bases in PCTs to local authorities. Indeed, many of them are already in local authorities. As I said, 13 of the 14 appointments of DPHs in my region are joint appointments. They are already well integrated and have trainees in public health operating successfully within the local authority area. While I can see the theoretical risk to training, I believe that smooth transference will be achieved without too much difficulty.

Q394 David Tredinnick: The Unite union, when they came before us, told us that they feared councils could disperse public health staff across their organisations, leaving those staff without sufficient professional support, coaching, management and mentoring. Is that a risk to the future work force development or is that something you disagree with?

Dr Scally: Were it to happen, it would be, but I do not believe for a moment that it will. Directors of public health have a clear leadership role and I would hope that they would have public health staff working across the different aspects of a local authority but under clear leadership. In fact, I go back to the Health Select Committee report on public health some 10 years ago which pointed out the importance of the leadership role of directors of public health. A key part of their leadership role is to lead that team within the local authority, irrespective of where public health people are working within that local authority.

Professor Maryon-Davis: I agree with Dr Scally, but to help that process along it is important that the directors of public health have control of their own bit of the budget that they are given, however small it might be. That will help to make sure that there is cohesion within the local authority.

Q395 David Tredinnick: Fine. Thank you for that. I am going to ask lots of supplementaries, but I will have to keep an eye on the clock. How should public health fit into the new systems for clinical work force planning, education and training that the Government is currently developing?

Professor Maryon-Davis: Public health should be an important component of clinical training as well, and certainly there is a lot of interest from some of the clinicians to embed public health within their training. For instance, GPs are very interested in having a public health module within their training programme. The paediatricians are very interested in them having public health, because it is so important for children’s health, as are psychiatrists and others. There is a move, and there is work going on with the Faculty of Public Health in particular, to try to work through training programmes that incorporate an element of public health within clinical training.

Q396 David Tredinnick: How big a danger is it that in the future public health could be less attractive as a career choice for doctors and dentists? I think one of you already said that it is down to the money. Are there any other factors in there? How could you mitigate those concerns?

Dr Scally: I do not think it was down to the money.

Professor Maryon-Davis: It is not down to the money, but it is a factor.

Q397 David Tredinnick: Proper remuneration?

Dr Scally: It is a potential factor, yes, and of course people will be concerned. It is very important that we have a public health specialism within medicine that doctors want to go into that can provide them with a fulfilling career. That has a lot to do with how the system is structured and operates locally.

Q398 David Tredinnick: Thank you. The academic public health work force has an important role to play-I am sure you will agree-not least in the work of the Public Health Observatories, about which we have had discussion this morning. How satisfied are you that sufficient attention has been paid to the future of this particular strand of the public health work force?

Professor Maryon-Davis: We heard from Professor Newton this morning about the plans for the observatories to be absorbed into Public Health England. My worry is in the transition to that position, because we are seeing what I would call the dissolution of the observatories. We are seeing senior people in the observatories leaving-rushing to academia or taking early retirement-basically because of all the uncertainty and unrest. My main concern is with what is happening during the transition period. Ultimately, the vision painted by the civil servants earlier on, at the end of that process, is a reasonably rosy one, aside from the fact that an Executive agency is still a branch of Government and that the people who work for it are still civil servants. What restrictions will that imply in terms of their independent voice? I do have continuing concerns about that.

Q399 David Tredinnick: I must say that when the representatives of the observatories came before us earlier in the year they presented incredibly well and one got the impression that this was a first-class integrated datagathering system.

Professor Maryon-Davis: It certainly is.

Q400 David Tredinnick: Now there is a degree of haemorrhaging and there will have to be some major repairs, effectively. Is that right?

Professor Maryon-Davis: That is my view.

Dr Scally: Sir Liam Donaldson caught it quite well when he described the observatories on more than one occasion as the Crown jewels of public health. It would be unfortunate if there were any diminishing in the lustre of those Crown jewels, particularly in terms of their ability to support local directors of public health, local authorities and all of the work that needs to be done to contribute to the joint strategic needs assessments.

Q401 David Tredinnick: I have one final question. You have both, gentlemen, had very long careers by the sound of it. Dr Scally, you said you had been through seven transmogrifications-whatever the word is.

Dr Scally: It is six, I think. I am in my seventh.

Q402 David Tredinnick: That is going right the way back to when you were training. When you look at the landscape now, with particular reference to what we are discussing this morning, is there anything that really worries each of you? Is there something there that you personally would like to get on the record today so that we could perhaps look at it later?

Dr Scally: Not from my point of view.

Professor Maryon-Davis: He is a civil servant.

Chair: Professor?

Professor Maryon-Davis: This is by far the biggest shakeup that I have been through. I have been through as many as Gabriel-probably more-but this is by far the biggest and the most disturbing. We will not rehearse all the stuff about "Why?", "Why bother?", "Why now?" and all those other things. Given that it is happening, from the public health professional point of view, the most worrying aspect is the potential fragmentation of public health not just as a profession but as a service to the public as well. The Government missed a trick in not having a public health person on the commissioning boards. That was a great mistake, and I think work will have to be done to make sure that that input gets in there. The crosstalk at the local level is important, that the Health and Wellbeing Boards and the commissioning boards-consortia groups-do crosstalk. Public health can play an important part in that, but that has not been worked through yet. We might hear about that coming soon. The biggest worry is the fragmentation. There are concerns that training might also be fragmented and that might cause problems. We do have to get the regulation right and, as I have tried to say this morning, the time is absolutely right and we have a real opportunity now, especially in the way that the balance is changing in terms of the professional background of public health, to put in place, not at great expense, proper statutory regulation that would address quite a lot of the concerns that have been raised this morning.

Q403 Chair: Could we explore this concept of fragmentation? It is relevant to the debate about regulation too, is it not? You can have a coherent profession that works for a series of different employers and subscribes to a common professional ethic.

Dr Scally: Indeed.

Q404 Chair: Would it be fair to say that one of the arguments you would advance in favour of stronger regulation is that with a variety of employers the regulatory structure would address some of the fragmentation concerns?

Professor Maryon-Davis: The fact that we have a whole multiplicity of different employers adds real urgency to the need for statutory regulation. It is yet another reason why we should go for statutory regulation.

Dr Scally: Indeed. It also places the Faculty of Public Health in a key and vital position as the main professional organisation that is setting the standards for public health against which regulation will operate. The tasks falling to the Faculty and the distributive system of public health increase commensurate to the distribution.

Professor Maryon-Davis: I agree. I think the Faculty of Public Health will have to have a hugely expanded role in helping to mitigate some of the fragmentation we have talked about in working with the regulators to make sure that that regulation itself is fit for purpose. Yes, I agree. The Faculty’s role is going to be much greater.

Q405 Chair: Pushing you a bit further on the concept of fragmentation, currently, or traditionally, directors of public health have been employed by PCTs and, before that, local statutory health authorities of one sort or another, and they have been employed within the Department of Health. In the future they will be employed through Public Health England and through local authorities rather than through the health service. Why does that add up to fragmentation?

Professor Maryon-Davis: They will be working in a whole variety of different milieux. Some will be working for the private sector, which is going to expand as well, and some will be in academia, as we have heard.

Q406 Chair: Yes. What I am trying to test is your proposition that the world in five years’ time is more fragmented, from a public health perspective, than it was five years ago. It is not immediately obvious to me that that is true.

Dr Scally: I do not think, Chairman, it has to be true, but it could be true if directors of public health moved to local authorities and we did not have the right structures in place to ensure that they remained within a coherent system. What we are trying to create for the country is a public health system that will serve us well for the coming years. It is the systemisation of public health that will ensure we retain coherence. If we do not have a system and we do not have coherence, then the fragmentation could very easily happen.

Q407 Chair: As to the fragmentation, I think I am hearing you say that the danger is isolation.

Dr Scally: Indeed.

Q408 Chair: And that that leads to fragmentation, but actually the institutional structure is no more fragmented in the Government’s intended world than it has been. The danger is that the culture in the local authorities is more isolated than the culture in the health service.

Dr Scally: That is right. In terms of professional accountability, the lines are redrawn. For example, I am very clear about the professional accountability of the directors of public health in my region. I sit within the strategic health authority and I have an organisational role then with the PCTs accountable to the strategic health authority, so it is very easy to maintain coherence and to encourage collective activity. If that collective activity falls away, it will be greatly to the detriment of public health because some of the really good things we do are done collectively, like the regional offices of tobacco control and the fantastic work they are doing with smoking, or our office in sexual health about integrating sexual health service approaches across the region. Unless we have a systematic approach to creating a system, then I do fear fragmentation.

Chair: Are there any other questions?

Q409 Rosie Cooper: What would you put into the system today to stop that happening? If directors of public health are not directorlevel employees at local authorities, that fragmentation will start, will it not?

Chair: I think we were given the broadest possible hint today that that is an issue the Government is going to address in a few days’ time.

Professor Maryon-Davis: The Faculty of Public Health can have an important unifying role across this potentially fragmented service by making sure that the standards are set equivalently across the system, so there are not differences in quality across the system, that the training programmes again use the whole system and not just bits of it and that communications between members of the Faculty working in different settings are there to help to encourage networks at local level, in particular, or the subnational level and so on. Therefore, the professional body-the UK Faculty of Public Health-does have an important role in helping to mitigate the potential fragmentation that might occur.

Chair: We try to draw these sessions to a close by 1 o’clock. We are three minutes adrift, so thank you very much indeed for your evidence this morning. Thank you.

Prepared 15th July 2011