Communities and Local Government Committee - Minutes of EvidenceHC 694

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Oral Evidence

Taken before the Communities and Local Government Committee

on Monday 26 November 2012

Members present:

Mr Clive Betts (Chair)

Bob Blackman

Simon Danczuk

Bill Esterson

Mark Pawsey

John Stevenson


Examination of Witnesses

Witnesses: Councillor Steve Bedser, Member, Community Wellbeing Board, Local Government Association, Dr Peter Carter, Chief Executive, Royal College of Nursing, Councillor Alan Connett, Executive Lead for Health and Wellbeing, District Councils’ Network, Professor Gabriel Scally, Director of WHO Collaborating Centre for Healthy Urban Environments, University of the West of England, and Dr Penelope Toff, Co-Chair, Public Health Medicine Committee, British Medical Association, gave evidence.

Q49 Chair: We welcome all of you to our second evidence session of the inquiry into the role of local authorities in health issues. Thank you very much for coming to give evidence this afternoon. For the sake of our records, please say who you are and the organisation you represent. That would be helpful to us.

Dr Toff: Dr Penelope Toff. I am Co-Chair of BMA’s Public Health Medicine Committee, and Consultant in Public Health Medicine and Deputy Director of Public Health from NHS Brent.

Professor Scally: Gabriel Scally. I am currently Professor of Public Health and Planning at the University of the West of England, where I am Director of the WHO Collaborating Centre for Healthy Urban Environments, and I am a former Regional Director of Public Health.

Councillor Alan Connett: Councillor Alan Connett; I am lead spokesman on health and wellbeing for the District Councils’ Network. I am a member of Teignbridge District Council and Devon County Council.

Dr Carter: I am Peter Carter, Chief Executive of the Royal College of Nursing.

Councillor Steve Bedser: Hello, I am Councillor Steve Bedser. I am here representing the Local Government Association Community Wellbeing Board, and I am the Cabinet Member for Health and Wellbeing on Birmingham City Council.

Q50 Chair: You are most welcome. There are five of you; it is quite a large panel. If you find yourself agreeing with something someone else has said, an indication that you agree without repeating everything is helpful to move us along, because we have quite a wideranging area that we would like to cover with you. With regard to the proposals for the transfer of the public health role to local government-or the reintroduction of public health to local government, as some people remind us, given the history of it-what do you think is wrong with the current arrangement? Is it essentially that the NHS has marginalised public health and hopefully the changes will bring it back to centre stage?

Councillor Steve Bedser: I am hesitant to criticise the NHS for the history of the last two or three decades, but it is very clear that the return of public health to local government, and indeed there are environmental health colleagues who will say the joining up of the public health family into local government, is something we welcome. If you think about the functions of local government and take a social view of the determinants of health, so understanding that people’s health status is driven by their housing, education and employment status, it makes tremendous sense for the function of the public sector that is responsible for driving the public health agenda and reducing health inequality to sit alongside all of the other services that have an opportunity to affect people’s life chances and health status, rather than being conjoined with the bit of the system that is dealing with people once it is too late in public health terms, i.e. fixing people once they are ill. It is a welcome opportunity. If you think about the range of views associated with the Health and Social Care Act, it is quite significant that this is one that enjoys perhaps the most unified support.

Dr Carter: If I could complement that, we had and still have significant reservations about the Health and Social Care Act. However, we think this part really makes sense. Eons ago it was ill-advised to have taken this away from local government, and I think it gives a wonderful opportunity to give public health the profile and focus that is needed. As Councillor Bedser says, the health service is under huge strain at the moment. That is not a criticism of the health service; it is a fact. In some areas the NHS has done well over the years, but we could do much better on the preventative aspect of the nation’s health.

Councillor Alan Connett: From our point of view the benefit of return is that there will be a more holistic approach to public health. Our view generally about the new arrangement is that the significant contributor, the district councils, do not receive a parity of esteem. Nonetheless, it is much better that all the parties are working together rather than seeing it in isolation as an NHS priority.

Professor Scally: I have long supported public health returning to local government, although I wish it were happening under more auspicious conditions than at present. However, it is not a full return to public health. When you look at the allocation of responsibilities, a substantial amount of those responsibilities are going to the National NHS Commissioning Board and to Public Health England, which is an integral part of the Department of Health, and being centralised in the civil service, so it is not a full transfer.

Q51 Chair: Would you have transferred the lot then?

Professor Scally: I think there is a discussion to be had, which we may well come to, about infectious disease and emergency planning and so on. I think it is a matter for regret that the directors of public health will be the first public health officials in local government ever, or medical officers of health, who have had no responsibility, for example, for childhood immunisation. That responsibility will be with the NHS Commissioning Board. There are serious problems around the allocation of resources and functions, but in general I think local government provides very many welcome opportunities.

Dr Toff: I agree with much of what has been said. The problem to date has been that, although there were many joint appointments of directors of public health, there was not always the joint working that should have gone on with local authorities, which could have really made a difference to the wider determinants of health. However, where those relationships were working well, we have some really good examples of the kind of work that can be done, and the move into local authorities should make that much more achievable.

I agree with the comments about fragmentation. We do not want to go from a situation where we had some fragmentation to one where we have even more, so we need to guard against that. I also think there were advantages for some directors of public health and public health teams within the NHS in that they had a certain amount of independence, and that lent credibility to the advice that they gave. It is very important that they are positioned in such a way in local authorities that they do retain that independence and use it to the best of their ability.

Q52 Chair: Just to pick up one issue there, you mentioned that some areas have already got good working relationships and various partnerships. Would it be possible to just carry on building those rather than the organisational changes that we are now faced with?

Professor Scally: Primary care trusts are disappearing and a lot of their functions with them. It would be very difficult to see a DPH operating, for example, within clinical commissioning groups. Secondly, there has been a significant breach in coterminosity around the clinical commissioning groups and local government areas, so I think there would be difficulties continuing.

Q53 John Stevenson: We have talked about public health originally being part of local government, then in turn part of the NHS, and now it is returning to local government. Quite clearly there are cultural differences between how things were conducted under the NHS and how they will be, or have been in the past, under local government. The BMA have expressed concerns that some local authorities see public health as any activity that improves the health of the population rather than as a distinct health speciality. Should we be concerned about that?

Dr Toff: There is a concern because at the moment there is not a full and meaningful understanding of what public health is as a specialty. There are public health services that are in many cases already provided to some extent by local authorities, which can be extended and improved upon in terms of serving the population’s health. We have to distinguish between those and public health services provided by public health specialists currently, and the huge breadth that those services cover across the different domains of public health. Most local authorities are more aware of the work done in health improvement, often because there has already been collaboration in those areas, than they are of the work that is done at local level in health protection and in supporting the commissioning of healthcare services.

Dr Carter: I do not think the clash of culture will necessarily be a problem. Sadly, one of the things that have bedevilled the NHS over many decades has been the perpetual reorganisation. NHS staff are used to working with different organisations and different architecture every few years. The biggest issue for us is that, by transferring across, we want to make sure there is not a brain drain and people with skills feel disinclined to come across. Particularly in relation to nursing staff, we need to ensure there is parity in terms of pay, pensions, and terms and conditions, but culturally our members overall think this is a very sensible move.

Q54 John Stevenson: Do you see it as a more stable environment?

Dr Carter: If it is allowed to mature, bed in, and is not subject to another reorganisation, this would be a sensible way forward for us. Local elected councillors tend to be people who have lived in the constituency and have a long-term perspective. Ultimately if it is allowed to bed in, there could be a much more stable and sensible approach to planning.

Councillor Steve Bedser: If you look at it objectively, the people who currently work in public health are going through a period of significant organisational change. I have had experience both of working in the health service and as an elected member. They are two very different cultures. At an individual level, people react to that differently. Some people will embrace the change and find it exciting, and others will be very worried. Mixed in with that, across the public sector, is a judicious amount of concern about job security, but I do not think there is a fundamental problem with making the transition. I have not heard the concern about public health being seen as about health inequality rather than a speciality. It is a sizeable resource that is transferring across, and I would be very concerned if people were not looking at that objectively as something that would be about driving health improvement and reducing health inequality, because that is the job we need to do. In my local authority we have got an 11-year gap in life expectancy between the rich and the poor. If public health is not going to play its part in helping the local authority close that gap, then I struggle to understand what its purpose is.

Q55 John Stevenson: Professor Scally, you have expressed some concerns about the position of the public health function within local authorities. What are your concerns there? Do you feel that it will be dominated by other aspects of local government, or do you feel that people coming from the NHS will be seen as a threat by the current employees of the local government?

Professor Scally: On the latter, I do not think so; I am not concerned about that. Although just to address that one point, I do think there is an enormous amount more that should be done to spread public health skills across local authorities. In the South West, where I was regional director of public health, we had paid for 57 or 59 people, nearly all of them from local authority backgrounds, to do diplomas or masters in public health. I know, as a director of public health, if I am having discussions with transport officials or leisure services officials, it is so much easier if they understand what public health is about in the first place. So I think there should be more widely spread public health skills.

My concerns about the transfer relate to the power and influence of the director of public health and his or her team, and their station within local authorities. We will see of course when it actually happens on 1 April where the location is, but I hear far too many reports of directors of public health potentially ending up as third in line, reporting to other directors, such as directors of adult social care, and being seen as part of that. Some directors of adult social care are making a very deliberate play to take over public health. After all, it is all about wellbeing, is it not? I know when those issues have been raised, the point has been made about the size of budgets. I do not regard that as a good basis for planning the structure of organisations when it comes to dealing with health, so I am concerned about their positioning.

Q56 John Stevenson: Where do you think it should be placed?

Professor Scally: I did attempt to prosecute my view on this, but I did not get very far. We should have a properly staffed office of the director of public health in each local authority, and it would report directly to the chief executive, or the executive leader of the council. It would not be in competition for the resources of the big budget holders and would be seen as a source of professional expertise across the council’s business.

Q57 Mark Pawsey: There is a pretty universal acceptance that the return of public health to local authorities is a good thing. I particularly want to pick up with Councillor Connett, if I may, the omission of district councils from the health and wellbeing board. I am a former councillor on a district council and meet with my colleagues regularly. I think they are feeling a little bit left out, after all they are responsible for environmental health, housing and planning. Do you regard the omission of district councillors as a significant one?

Councillor Alan Connett: Yes, I do. The District Councils’ Network has done research, and district councils feel that they have not been able to engage as fully. Certainly, over the past 12 months, more councils are feeling more engaged. There has been a change from about 64% to 86% in councils now feeling that they are engaged. A lot of the statutory responsibilities actually sit with district councils; as you were saying, planning, housing and some of the economic development activities play a fundamental role in delivering better public health. I called it earlier the lack of parity of esteem: not having a dedicated seat at the table is reducing the opportunity for the public sector to work fully in delivering the requirements of the Act.

Q58 Mark Pawsey: Do you think that the Government’s objectives are less likely to be met because of that omission? Professor Scally spoke about the need for the director of public health to be able to engage with professionals responsible in those sectors. Do you think that informal links will be made or do you think the omission from the health and wellbeing board is a really serious one and will stop us achieving what we want to achieve as a consequence?

Councillor Alan Connett: I think it makes it harder to achieve. Your words were "less likely". I would not disagree with that; I think it makes it harder to achieve. In most places I suspect there will be very good informal links, but that is not the same as being part of a decision-making process. Given the role that districts have, that seems to be an omission.

Q59 Mark Pawsey: Councillor Bedser, this will not concern you terribly because you are not from a two-tier authority, but have you got a view about it?

Councillor Steve Bedser: It is an observation, and Alan I were talking about this before we came to give evidence. I will leave Alan to speak for himself on behalf of district councils, because it is not a world I directly inherit. All health and wellbeing boards will inherit a degree of complexity. In my own situation we have got devolved structures that have given us 10 districts and four clinical commissioning groups. I am chair of the health and wellbeing board, and if we had everybody who wanted to be around that table, we would be holding our meetings in a stadium rather than a committee room.

We have all got different types of complexity to understand and embrace. If I was the chair of a health and wellbeing board in a county situation, I would not understand the opportunities and the challenge if I did not proactively engage my colleagues and representatives from district councils, so it is a measure of the quality of the partnership and leadership that is given by the health and wellbeing board. I think the external scrutiny and some of the peer and mentoring support that the Local Government Association will give to authorities that are perhaps struggling to implement the new structures is about that critical frank challenge to ask, "How are you involving other partners in two-tier situations?" or indeed, in my own situation, "How are you getting proper localism embedded into a unitary structure?"

Professor Scally: Health and wellbeing boards are a really interesting topic. I was the director of public health in Northern Ireland-chief administrative medical officer in Northern Ireland-and I arrived in England in 1993, just in time to see the last of the joint planning committees between health authorities and local authorities. In my limited experience of those, some of them worked extraordinarily well but some worked extraordinarily badly, resulting in pitched battles about the use of resources and who would pay for which particular aspect of care. I am extremely worried about health and wellbeing boards when you read the remit that the Department of Health has consulted on. It is largely about the commissioning of services, and you have to get well down the first page of that very short document before you come across health and wellbeing in its broadest sense.

Q60 Mark Pawsey: So do you consider public health itself is not a big enough priority on health and wellbeing boards in the first place?

Professor Scally: I personally think the construction of health and wellbeing boards is largely to do with the NHS and adult social care interface. In all my experience of working in the NHS and the Department of Health, that is where the concern lies. There is a great desire, for perfectly legitimate reasons, that there should be a very good working relationship around those issues, but I do fear that public health concerns and the overall health of the population will lose out. That is built upon by the fractured nature of the responsibilities. As you so accurately pointed out, district councils control many of the important determinants of health, including being the place where our separated brethren in environmental health reside.

Dr Carter: Yes, this is where we have some concerns. These things are not hardwired enough. We are not quite sure where the accountability lines are. Of course, a lot of it is to do with relationships and partnerships; that has always been the case and always will be. What you need is more detail, particularly on the accountability.

I would just briefly go back to Mr Stevenson’s point, and I agree with Professor Scally: in terms of the accountability of directors of public health, we feel very strongly that they should be accountable to chief executives because of the nature of the role. If they are third in line, you will lose the focus that is badly needed, particularly in England with the types of issues that we are seeing to do with health equalities and the health of the nation.

Q61 Mark Pawsey: Dr Toff, do you have a view about the omission of district councils?

Dr Toff: It is not my particular area of expertise. I think the director of public health is probably quite key in this, because one way into this is through the joint strategic needs assessment. Whatever arrangements are made, it is really important that all the localities are considered within that, and all of the differing local needs. Clearly, even though the recommendation from the King’s Fund is ultimately you do not want to have a huge core team there because the health and wellbeing board is probably not going to function well under those circumstances, you do have to find a very clear mechanism for the input of the district councils and all the other groups who you also need to take into account.

Q62 Mark Pawsey: I put it to you then that, if the health and wellbeing boards are about preventative work as the substantial priority, it might be more important for district councillors to be there than members of the clinical commissioning groups, who will get involved particularly when people become ill. The key objective of public health is to prevent people from becoming ill. Are the priorities wrong? Should the councillors be there instead of the CCGs?

Dr Toff: I do not think they should be there instead of the CCGs; both aspects of this are important. If you do not get the prevention right, the CCGs are going to struggle to deliver their part of the equation. The input from the directors of public health in particular needs to be seen as absolutely key here on both sides of that, from the point of view of the JSNA and the health and wellbeing strategy.

As another member of the panel has said, at the moment it is not clear how health and wellbeing boards will be held to account for that, and for including all the aspects that they need to include, and also for the public health input into the commissioning of services. They will be very key in that respect on health and wellbeing boards so that the boards have credibility in the eyes of the CCGs.

Q63 Simon Danczuk: Should objectives for public health be defined by central Government or locally?

Dr Toff: The public health outcomes framework that we have at the moment as a way of monitoring what is going on locally is a very sound framework. It covers a huge range of areas, and some of that is based on the very successful work of the health profiles that predated it, but it is not exclusive. Clearly there are other things that need to be taken into account, and other sources of data and mentoring that need to be looked at.

In terms of the health and wellbeing boards agenda, particularly around integrated care, in order to reinforce the positive working together and the putting aside of individual agendas that will be required, it would probably be helpful to have a more overarching national framework around integrated care and what should be achieved.

Q64 Simon Danczuk: Are there any other views on that?

Professor Scally: I think it needs to be both, and more than both. Identifying ways in which the health of the population can be improved needs to be a responsibility right across civil society. I can give you a very practical example of that. We have had data sets produced for some years now, and very recently, looking at the health of local areas and comparing them with the health of England as a whole. Large parts of my region, the South West, were completely useless because the health of the South West is very good. Many of our local authorities had nearly all of their indicators better than the English average. How dispiriting or difficult is it for a direct of public health to have that sort of report? It missed out on the fact that for many of those same indicators, the overall position of England is so much worse than other countries. So I think it requires national and local analysis and strategies, and the mixture of both should be able to address the health needs.

Q65 Simon Danczuk: Supposing they clash though, Professor?

Professor Scally: If they clash, they clash, and you work out how they clash. I have spent the last five or 10 years of my professional life trying to frustrate the Government’s ambition to reduce health inequalities in this country. The target was set as the difference between the top 10% of local authority areas and the worst 10%. We did not have any in the worst 10% and we had some in the top 10%. So the best I could do, as a regional director of public health, to help the achievement of that target was do nothing, or in fact make the health of the territories I was responsible for worse. I was not going to do that. Our local authorities were not going to sit back and do nothing in order to achieve such a daft target. So it has to be a mixture of both, and people must be allowed to act within the system in the interest of the population they serve, whether it is the population of England as a whole or the population of a local authority.

Q66 Simon Danczuk: Alan, do you want to comment?

Councillor Alan Connett: I would, Chairman. I share some of what Professor Scally says, but also within my own county of Devon there are quite significant health inequalities, and Devon must be able to respond to that. I personally feel, for the sake of labouring the point, that what we are missing here is an opportunity for the districts to be engaged on that. Ultimately life expectancy is lower in the north of Devon compared with the south of Devon; health and local authorities in the county as a sector need to be able to address that. I think the primary situation is for the local authorities to set their objectives.

Dr Carter: The common theme is that if you just rely on a local, federated approach, you will struggle. Equally, if you try to do this from Whitehall, you will struggle. You need some overarching principles. I travel all over the country in this job and I see huge differences. We need some overarching architecture. There are some common denominators, but you need to be able to say to local authorities, "You need to develop what is right for your area, otherwise you will really struggle."

Councillor Steve Bedser: I would echo some of that sentiment. I come from an area where 40% of our population are among the 10% most deprived in the country. The narrative of health inequality is very useful, but I recognise the merits of both national and local levers in focusing on outcomes. If we focus on the wiring diagrams or who is or is not in charge, we waste energy. We should be focusing on what makes a difference. Using a framework like Marmot to interpret your local situation, and then locally determine what needs to be done to make improvement, is a very helpful concept.

Q67 Simon Danczuk: In terms of what we should measure, should it be based on a particular aspect of public health, such as obesity, or should it be more general, such as healthy life expectancy? We could just measure happiness or something like that. Should it be precise or more broad and general? Any views?

Dr Toff: I just wanted to come back on your previous question.

Q68 Simon Danczuk: Are you going to answer this as well?

Dr Toff: As I said, the overarching outcomes around healthy life expectancy and reducing inequalities are the right ones, and it is important that the outcomes framework is based on evidence and what we know makes a difference. It is important for that reason, so I hope that answers that question.

Going back to the previous issue, there is a real problem around the lack of data that we have for marginalised and vulnerable communities. It will be very important locally to try to ensure that we do include those groups, in terms of the engagement of the health and wellbeing board and more broadly across the different areas of local government and public health, to make sure that we do engage properly with local communities and the local population. That can present a challenge in some areas, because different groups have different ways of engaging and require different communication strategies.

Q69 Simon Danczuk: Should we be measuring precise issues such as obesity, or more general things?

Dr Toff: I am trying to say that we can measure, for example, levels of childhood obesity, but we have to be very careful that when we are making measurements we do not fail to look at what is happening to groups that would not necessarily be included within those measurements.

Councillor Steve Bedser: I think the question you are asking is one best answered by the health and wellbeing boards. If you think about the shadow boards that are in place, and take the model of group dynamics, they are still very much forming and storming. We are going through a process of norming and performing, and actually having those contextual debates about what we are trying to do and what we are measuring through the local lens of what seems important. Drawing on the experience of Birmingham, deciding to focus on issues such as smoking and childhood obesity have been very helpful for achieving some of the other things that have been referred to in previous questions about engaging the right partners, setting the right cultural tone and helping people manage the transition from NHS to local authority. I think you should be very worried if any one of the panel was able to answer that question definitively now, because the process of understanding the right answer is part of the development.

Q70 Simon Danczuk: Before I move on to my final question, Professor, do you want to say anything?

Professor Scally: Yes, I do. I think this is a really important question, particularly the happiness issue. The WHO definition of health is a state of complete physical, mental and social wellbeing. It is in the preamble to the WHO Constitution, and I think is an absolutely correct formulation. It is a great pity that we are so reductionist in so many ways. I would point you towards Bhutan as a place to which I know Members of Parliament travel occasionally.

Q71 Chair: We are already looking at it.

Professor Scally: It would seem to be a good place to go, because they operate on the basis of gross national happiness. They have a very well constructed index, which comprises a huge range of indicators, including challenging things like the gender distribution of domestic labour. I think we need to move away from an obsession with GDP as being the only thing that matters.

In terms of what we should measure, I will not answer that any more other than to say we do need to try to get ahead of the game a bit. I have spent my public health life trying to catch up with things that have already arrived: the tidal waves of obesity and alcohol-related disease. We do need to seriously invest in trying to get ahead of some of these problems as a society to try to stop them. So it is not just picking our problems now; we also need the foresight.

Q72 Simon Danczuk: Let me just briefly move on to the final question for Alan and Steve. How should local authorities be held accountable for poor outcomes?

Councillor Alan Connett: I would say primarily through the continuing vibrancy of Healthwatch and the scrutiny committees, and ultimately via the electorate.

Councillor Steve Bedser: I am reluctant to be held to account from day one because in some local authorities we inherit very stark inequalities that have been ingrained for many, many decades.

Q73 Simon Danczuk: But Alan says if you do not get it right, you should be voted out at the next election.

Councillor Steve Bedser: There is a danger that health and wellbeing boards will start behaving in a knee-jerk, short-term way, driven by the electoral society. That would be very retrograde, which is why that balance of the triple key of local authority officers, elected members and representatives from bodies like clinical commissioning groups is very important.

Q74 Simon Danczuk: You cannot have it both ways, Steve. As you were saying earlier, you set your own priorities; you want to concentrate on smoking. Government used to advocate a top-down approach, reducing this and affecting that, for example, teenage pregnancies and so on, and working towards targets. You are saying you want to set it locally but not be held accountable.

Councillor Steve Bedser: There are clear accountability mechanisms in place; I am not saying we should not be held accountable. Things like health scrutiny and Healthwatch are going to be very important in keeping some local temperature in the relationships between health and wellbeing boards and the wider public. There will be the lens of the media. There are very strong levers that will hold us to account and so there should be.

Q75 Simon Danczuk: Quickly, I just want Peter to comment.

Dr Carter: I think you have touched on something very important: how do you measure the success? It has constantly been a problem for the health service. Every year there is a report published by an organisation called Dr Foster. We think there is a lot of very good stuff in it, but hospitals that come at the bottom of the ratings feel quite persecuted by it, when it is often a reflection of the population they are serving. These are often very good hospitals dealing with very unhealthy people.

In the first few years of these new arrangements, I think we need to be careful not to set unrealistic targets for local authorities, because this is about behavioural and lifestyle change. It will take a considerable amount of time before that supertanker begins to turn. You do not want people to be devising targets and outcomes that are measurable in a favourable way as opposed to coming to terms with the fact that, however much we do not like to accept it, the health of some parts of the nation is pretty desperate. We need to come to terms with that. The Chief Medical Officer, Sally Davies, pointed out last week that liver disease is increasing in England, unlike the rest of Western Europe, where it is decreasing. That is lifestyle related by and large, so if you are going to address that, you need to get a sensible understanding of how realistic it will be before you can start to turn that around.

Q76 Bob Blackman: We are moving on to financing and how that money should be spent and where it should be allocated. The money has been ring-fenced to ensure that it is spent for the purposes the Government intend. But local authorities have been very good at being creative in using that money. Penny or Gabriel, do you have any concerns about local authorities using existing services and saying, "Well, actually, that is health related, so we will take a portion of that money"? Should there be some safeguards put in place on this ring-fenced money?

Dr Toff: The money is ring-fenced, everyone understands that, and that seems to be very strongly supported both by the public health workforce and local authorities. I think the intention is that that money should be used to improve the population’s health. One of the most important safeguards will be the key role of the director of public health and their input right across local government, and not only in the more obvious areas of public health spend. The chief officer will advise, with the support of the broader public health network and their own public health specialist staff within the local authority, around whether that is an appropriate use of the money. I would just like to support the comments that were made earlier by Professor Scally and others around the position of the director of public health. This is one illustration of why it is so important that the director of public health does have a place at the top table and that direct accountability, not only so their advice is taken seriously and they maintain their independence and credibility, but also so they can work right across the local authority and give that kind of advice on a sound basis.

Q77 Bob Blackman: To give you an example, a local authority comes along and says, "Improving our sports centres and increasing participation in competitive sport will improve the health quality of all the people who live in our area, so I am going to raid the budget for public health." Is that a concern?

Dr Toff: I do not think that is necessarily a concern.

Bob Blackman: Right, okay.

Dr Toff: Part of what we all support about public health coming into local authorities, and local authorities being responsible for the broad public health remit, is that we can work across all of those determinants of health. That may be an appropriate use of the money under some circumstances. The issue is whether it is in line with what has been identified as being the local priorities, and to approach things in a way that says, "Okay, we are going to spend our money on this. What impact will it have on other areas we need to fund?" So I do not think you can make any blanket statement about whether it would be right to spend this money on a swimming pool or a playing field.

Q78 Bob Blackman: So the safeguard you would have is the director of health being at the top table and able to say, "Oi, hang on, stop"?

Dr Toff: I think that is absolutely crucial.

Q79 Bob Blackman: Thank you. Gabriel?

Professor Scally: Directors of public health are used to dealing with avaricious heads of finance. They have been fending off rogues and villains in the NHS for decades. The analysis that was done about the levels of funding and the variation of levels of funding going into public health locally was really quite shocking. There is no excuse for that, and NHS management must bear a huge amount of responsibility for that.

Sir Liam Donaldson pointed out in one of his annual reports some years ago how budgets were being reduced in public health, so this sort of behaviour would not be new to directors of public health. If they are given sufficient status in the organisation, I hope they would be able to cope appropriately with it. My challenge back would be: "Well, show me your evidence." There is no evidence at all that investing more in leisure centres will improve physical activity across the board.

Q80 Bob Blackman: I do not have to produce the evidence. I just have a view of what local authorities finance directors may do.

Professor Scally: Yes, but some of the talk has been really quite fanciful. It is not as if there is a big bag of gold sitting around that is not being spent elsewhere at the moment. The final allocations have not been made, but the bulk of the money so far is for drug services and sexual health services.

Q81 Bob Blackman: We are going to talk about that in a minute. Is there any other protection that you would like to see on these ring-fenced budgets?

Professor Scally: No, I think the ring-fencing is entirely appropriate and should be maintained.

Q82 Bob Blackman: Okay. Alan?

Councillor Alan Connett: I take an entirely different view. I do not favour ring-fenced budgets. If councils and health and wellbeing boards have set very clear, strategic objectives with a common view about how best to achieve it, then that is an appropriate way to spend money. Ring-fencing may create barriers where they need not exist.

Q83 Bob Blackman: So, just to be clear, that means that of the money that is given to a local authority for all of its services, there should be no ring-fencing of the public health budget?

Councillor Alan Connett: I am very clear.

Q84 Bob Blackman: That is fine. Peter?

Dr Carter: We think ring-fencing is absolutely essential, but there is something else I want to bring to the Committee’s attention. We have some concerns about how much money is being transferred across. In these difficult financial times, we are not convinced that the requisite funding is coming in the first place. Dr Stephen Watkins, who is a director of public health in Stockport, writing recently in the Health Service Journal, pointed out what with a study he had found 28 examples where significant sums of money are not being transferred across.

Q85 Bob Blackman: So just to be clear, that is money that is being spent at the moment on public health?

Dr Carter: Yes.

Q86 Bob Blackman: But not transferred to the local authorities.

Dr Carter: And not transferred across. So we do not want to set it up to fail before it starts. Then when it does come across, because obviously we would hope the right amount comes across, we do think ring-fencing is essential because over the years in the NHS-and we are great supporters of the NHS-it has been easy target to take money out of.

Q87 Bob Blackman: We have had evidence about the easy target. What safeguards, if any, would you want to make sure this ring-fenced money is not purloined for other purposes?

Dr Carter: The director of public health being accountable to the chief executive, appearing before the council and being clear about what the money is that is being allocated, and throughout the year being clear that it is not being purloined for other, probably well meaning causes, but at the expense of public health.

Q88 Bob Blackman: Okay, thank you. Steve?

Councillor Steve Bedser: I have several comments, but I preface any comment about money with the observation that it is now the end of November, and we still have no idea of any notional budget that is going to transfer across to us in April, which makes it quite difficult for us. We are preparing our budget consultation in my own authority, and we are going to a proper consultation process with the public and having to make working assumptions about the public health money that will transfer across.

The position of the LGA is very clear. It is against ring-fencing because it constrains local decision making, and the purpose of local government is to make local decisions within the framework that has been allocated to us by Government. I am an evangelist for public health; it is probably one of the most important things that local government could and should be doing. From my point of view, the drawback of a ring-fenced approach is it defines the limit of public health spend.

Q89 Bob Blackman: I have been reading about the problems Birmingham City Council have in terms of their overall budget. Your leader would be turning round and saying, "We are very sorry, but we will have to reduce this budget."

Councillor Steve Bedser: If you want to take Birmingham as a case in point-

Bob Blackman: I am just taking your budget because we know.

Councillor Steve Bedser: At the end of the economic cycle, we reckon that about 48% of our controllable spend will have been cut.

Q90 Bob Blackman: So surely being an evangelist for public health, you want to keep that money safe, do you not?

Councillor Steve Bedser: But in terms of achieving all of the potential that exists with the transfer of public health from the NHS to local government, if it comes in a hermetically sealed bag labelled "public health", the danger is that it then does not properly integrate with all of the functions of local government across the spectrum of housing, education and environmental health, and bring alive all of the very real opportunities that exist with the transfer.

Q91 Bob Blackman: Leisure centres are a classic example. They will enable more people to do exercise.

Councillor Steve Bedser: I think leisure centres have the potential to become engines of public health outcome. I invite Professor Scally to come and look at Birmingham, because by offering free access to physical activity in leisure centres for deprived communities, there has been significant uptake and improvement in people’s actual measurable health status.

Q92 Bob Blackman: I turn to the formula then, because one of the issues about the money that is going to be spent is how the formula is determined. We have heard about the potential inequalities in health. What should the formula focus on? Penny, maybe you would want to start on this. Should it be sexual health, children’s services, prevention of things, smoking cessation? How should that formula be structured? Getting that formula right will determine how much money each local authority area gets.

Dr Toff: Just to pick up on one of the points Steve made, I do not think all of this is about more money. A lot of it is about more intelligent and joined-up commissioning and integrated care. In terms of the formula, the allocation itself, I would just reiterate the concerns that have already been raised. The problem here is that this is based on existing spend. There are areas of historical low spend, and in those areas CCGs are going to struggle because the preventative agenda will not be being met.

The paper by Stephen Watkins that was referred to has been condensed into a letter. It has gone from the Chair of the BMA Council to the Minister of Public Health, outlining the reasons for the shortfall in the baseline allocation and making some suggestions about how that might be rectified. The issue of need has to come into the equation, and it is a very difficult one. In the immediate short term, we know that some local authorities will find themselves with a big shortfall, which has already caused them to make regrettable decisions about the transfer of public health into local authorities in some of the areas we have already mentioned in terms of the positioning and capacity of the workforce, which we can see being reduced already.

Q93 Bob Blackman: That is a general view, which I can accept, but should there be factors of particular elements of public health triggering how the formula works or should it be a global sum based on per head of population?

Dr Toff: I think the formula has to take into account the differing needs, but in the short term some action is required to bring up the amount of investment in public health because we know that there is going to be this serious shortfall, which will probably exacerbate the inequalities that are already there.

Bob Blackman: We cannot debate where that money would come from.

Professor Scally: I think the issue of the formula is extraordinarily difficult for the reasons I gave previously, in that substantial amounts of the money expected to come will be for extant services: substance misuse and sexual health services. I must point out that those services did not prosper in the NHS. For drug services the money had to be taken out of the NHS and put into a pooled treatment budget along with Home Office money. That is what enabled progress to be made on drug services, because it was not prospering in the NHS. In teenage pregnancy and sexual health services, we only made substantial progress in the last four or five years when there was significant additional money ring-fenced and earmarked for sexual health, because the NHS did not invest in it. So I am really worried about putting in a global sum that will then be preyed upon. I would favour a mixed pattern of budgets targeted towards the big service areas, and those are public health services that are delivered and need to be delivered in the future.

I would also argue that there should be a sum for the public health infrastructure. The success of public health under local government will not come around because of how these relatively small amounts of money are used; it will come through the influence of public health thinking pervading all of the actions and budgets under the control of the local authority. For that you need a director of public health, and adequate staff and resources to be able to produce that level of influence.

Q94 Bob Blackman: Steve, what about a formula for distribution of funds to local authorities? It is nothing new; we are all used to it.

Councillor Steve Bedser: One of the concerns we have is that the apparent allocation of money, which we do not yet know about, is going to be based on random and historic patterns of spend. The ideal of a rational way of apportioning the money would be instinctively appealing. There is one thing that public health is not short of, and that is data. So as an observation, it should not be too difficult to reach an agreement about what headline data we should be measuring to drive investment in public health in particular areas.

Q95 Bob Blackman: But are you happy that the formula is structured on particular sorts of needs?

Councillor Steve Bedser: My understanding is that the current deal on the table is historic spend. That is not attractive because that will not match actual need. So I, and I think the LGA, would very happily engage in a debate about matching the resource to need rather than history.

Q96 Bob Blackman: Okay, thank you. Alan, do you have a view on this?

Councillor Alan Connett: I very much share Steve’s view.

Q97 Bob Blackman: Thank you. Peter?

Dr Carter: I agree with Steve. One of the very good things is that we have rich data. What you need is a sophisticated local needs assessment, and then you target the resources where you think the greatest need is. Although I agree with Gabriel, these are, relatively speaking, small sums of money. Sadly, despite the previous Government tripling investment in the NHS, a huge opportunity was lost to really get upstream in that good financial climate. That did not happen and we now know where we are.

Q98 Bob Blackman: Finally from me, in relation to the health premium, which will not come in for two-and-a-half to three years, do you have any concerns that this will either incentivise or reinforce poor performance? Will it actually reward the good performers or reward the bad performers?

Councillor Alan Connett: My view would be that, because at the moment it is unlikely to be shared with district councillors, and they are a key player, it may not act as the incentive that the system would like it to be. For that reason I think it is essential that the premium is shared appropriately with the sectors involved.

Q99 Bob Blackman: Okay. Steve?

Councillor Steve Bedser: My personal view is that, given the complexity and amount of change that we are dealing with at the moment, the health premiums still feel very, very abstract and difficult to conceive.

Q100 Bob Blackman: But after you have thrown open all these leisure centres in Birmingham to the people that have ill health, you will improve their health and you will get a big incentive to be paid.

Councillor Steve Bedser: That would be very attractive and rewarding. It does not always work out like that, but if the system rewards good behaviour and incentivises people to do more, then that would be a good thing. But it does feel very abstract talking about something that is not going to take hold in the system for two or three years.

Professor Scally: The nature of public health is that, with some exceptions, generally timescales are too long to make the health premium an attractive prospect. I do not think it is right. There does need to be a mechanism to reward local authorities that have put in effort and really bent their backs to this new task of improving health.

Q101 Bob Blackman: Should that be on the basis of the baseline data of performance when they take over, and then a year later, or two or three years later? If the outcomes are better, then they get a financial reward. Is that the way it should work?

Professor Scally: It may take some time for the outcomes to become apparent, but there are process measures that could be in place. I personally favour a system of accreditation of local authorities for public health, with judgments to be made around how well they are doing across a broad range of categories. I would put just one caveat, in that there should be no health premium to any local authority that maintains pension investment in the tobacco industry.

Q102 Bob Blackman: Okay, thank you. Peter or Penny, do you want to comment?

Dr Carter: I think it has been covered.

Dr Toff: I do not have too much to add. I would just agree with Professor Scally.

Bob Blackman: If you agree, that is fine.

Dr Toff: People have already mentioned the local agenda and making sure that the priorities are right at a local level. I think that needs to be constantly monitored. You would not want places to be penalised because they have realised midstream that perhaps actions they decided upon were not the correct ones. You would want them to be open to advice, particularly from public health specialists looking at the data in an ongoing way, that perhaps they needed to change their approach. That would then prolong the timescale again, and I do not think that you would want to dissuade people from that activity.

Q103 Chair: Professor Scally, who would do the accrediting?

Professor Scally: I think there should be an accreditation system set up by the LGA and by the Faculty of Public Health. A system has already been established within the NHS for pathology; it is long standing-20 years-and in the United States in September of last year they launched their accreditation system of local health departments in states and counties. I think we could very well follow their example.

Q104 Mark Pawsey: I just want to ask some questions about resilience and the commissioning of public health services under the new arrangements. On resilience, if there is an emergency outbreak, an epidemic, the Government is looking to Public Health England to bring people together to deal with that. Professor Scally, I think you are fairly critical of that proposal. Can you tell us why?

Professor Scally: I am, and I look forward to hearing Dr Toff’s views on this. I listened to last week’s session and the evidence from Duncan Selbie, and the assurances he gave, which I believe absolutely. I believe that Public Health England will continue to provide an excellent service, as it does in dealing with chemical spillages or infectious disease outbreaks. But I am not as convinced that the system as a whole will work, for a number of reasons. Reading the materials, it is not clear to me who would be in charge of an outbreak at the local level. Public Health England is part of the Department of Health; they are civil servants and they serve different masters. I am not convinced that if we have a problem across a substantial part or the whole of the country, Public Health England would be able to provide enough staff to lead in every local area. I believe it should be the local director of public health and the local authority that leads that function, but that is not clear to me at all.

I am also concerned about the structures and organisation of the NHS. Some of their structures are cutting across the local resilience fora, which, as you know, are charged with emergency planning. I am also concerned that the move of services, particularly community services, out of the NHS either to the private sector or to social enterprises will make it extraordinarily difficult to mobilise staff in the case of an emergency. There may well be clauses and contracts, and we could argue about that at the inquiry or in court afterwards. The good thing about the NHS system as it has operated in the past is it has been possible to mobilise staff very rapidly, and I fear the loss of that.

Q105 Mark Pawsey: We ought to ask the local authority representatives then. Do you feel able to step up to the mark or do you share Professor Scally’s concerns?

Councillor Steve Bedser: In this period of managing the transition, I have been encouraging whole swaths of the NHS and local government not to obsess about structures and wiring diagrams, and to focus on relationship building and partnership.

Mark Pawsey: But people need to understand the structures, do they not?

Councillor Steve Bedser: But in this particular regard it is very clear to me that we need unambiguous wiring diagrams. Certainly in my own local authority we will be testing to make sure that there is very clear understanding of the role of Public Health England and the role of the local authority, and there will be tremendous goodwill in terms of stepping up to the plate and mobilising staff across the local authority and, indeed, still the Health Service in an emergency. But we need a very clear line of sight from top to bottom of who is in charge, who is calling the shots, who is accountable, and we need to be satisfied as a health and wellbeing board that we properly understand that in our local context.

As with several of the questions that have been asked today-we have talked about performance and accountability-there is a role for the Local Government Association. We have got 152 local authorities, and when we see that there are a small handful of authorities struggling with the new arrangements, that is where organisations like the Local Government Association can step in and give additional and intensive support. It is absolutely clear that when there is a public health emergency, we need to understand who is in charge so that we can get on and fix the problem.

Q106 Mark Pawsey: Dr Carter and Dr Toff, is the involvement of local authorities in an emergency such as this going to be helpful, or will it be another layer of consultation and bureaucracy getting in the way?

Dr Carter: I would say it is essential. This is one of the unintended consequences of these reforms, which I think some did not fully understand.

Q107 Mark Pawsey: This is an unintended consequence?

Dr Carter: Yes, there is real risk with this stuff. In this transition it is still not entirely clear who is going to be doing what, and that is not good. Having said that, one of the characteristics of the NHS and local government is in times of crisis they do tend to pull together really well, but we should not be relying on that. We are just a few months away now from the biggest change in the NHS, and with this transfer back there has been the huge distraction of the very things that Steve has talked about: jobs, structures and the rest of it. People are looking out for their own employment, quite understandably.

Q108 Mark Pawsey: Are you asking for a template then? Do you want Government to write a template to be applied to every local authority?

Dr Carter: No, it should be clear, certainly by 1 April, what the contingency plans are. Who is responsible? When you press the hot button, who is the person on the spot that is going to be taking control? That is still not clear at this stage, and that is not good.

Q109 Mark Pawsey: Dr Toff?

Dr Toff: I agree with Peter and the others’ comments. Ultimately local relationships will continue to be absolutely key in this. As others have articulated, it is an area of huge concern at the moment because it is spread across so many different organisations, it is very complex and there is very poor understanding of it. It is reliant on each of those organisations defining what their role is and making sure that they have the right structures, financing and staff in place to fulfil that role.

The other half of the equation is clearly placed firmly upon the director of public health, so it will be extremely important that they are given the resources and freedom to exercise that role in bringing the whole thing together locally, probably jointly with the local NHS Commissioning Board. The structures are very complex and not at all transparent to most people, and my main concern at the moment is what we are seeing as a result of that is huge variation. In some places people have worked very well together to set up health protection fora and so on to make sure that they do have the proper provision in place. In other local authorities, health protection has barely been mentioned or considered.

Q110 Mark Pawsey: Particularly in relation to emergencies, do you think there is a conflict between the 15 Public Health England centres that will be set up, and the 39 local resilience forums? How are those two bodies going to relate to one another?

Dr Toff: We really do welcome Duncan Selbie’s assurances. I also have great confidence that, although they now only have four months to put everything in place, what they are going to provide is basically on the footprint of the Health Protection Agency’s previous contribution. I do not see that as being a huge issue, but there is some realignment of relationships. There is now a responsibility that will be placed on the NHS Commissioning Board’s local centres, which was not there before, to make sure that there is that capacity on the NHS side to respond to these emergencies. The only way we will really know about this is if there is a thorough scoping exercise carried out, and lots of training and rehearsing of scenarios. We will need to test this out to see whether it works.

Q111 Mark Pawsey: Right. Professor Scally, to whom do we look to provide this clarity that you suggest is currently lacking?

Professor Scally: I think the Department of Health and the Department for Communities and Local Government should be responsible, or perhaps the Cabinet Office in their overall contingencies role. I do not want to be sitting and talking about this in the aftermath of something that goes wrong.

Q112 Mark Pawsey: Is that your fear?

Professor Scally: That is my fear, yes. I have seen enough major incidents in my time to think that this is worrying. I know the lack of clarity worries directors of public health at a local level because some of the documents are internally contradictory about who is in charge.

Q113 Mark Pawsey: Right, if we move on to the commissioning of services, that will be carried out by Public Health England, local authorities and the local NHS Commissioning Board together. Is that going to give more clarity to the commissioning of public health services than the system we have been working with up to now?

Dr Carter: Yes, we are worried about this. We now have a lot of bodies and we are still not sure how it is all joined up. We are concerned about the fragmentation. You could get people falling through the cracks, and that might result in an increase in the postcode lottery. That will not be in anyone’s interest, irrespective of where they are in this situation. So again, just to repeat myself, these reforms are still not without risk.

Q114 Mark Pawsey: Are these uncertainties so serious that you would suggest a delay in implementation?

Dr Carter: I do not think you can now. This thing is moving forward, there are people involved, people looking for jobs, job security and it needs to happen. We are only talking about 16 or 17 weeks away, so there has to be a real focus on how this is joined up otherwise you are really in danger of people unintentionally falling through the gaps and the postcode lottery increasing.

Q115 Mark Pawsey: Dr Toff, are you equally pessimistic?

Dr Toff: I do see that on the one hand most local authorities are going about this in a highly conscientious manner, and very much want to make sure that there is a very effective, safe transfer of commissioning contracts over into local authorities. I think there is predominantly a failure to understand the Public Health England role and their input into commissioning and that they will be a very key link between these different bodies, so that is an issue.

Q116 Mark Pawsey: Given a free hand, how would you get to where you would like to see us? What could be done?

Dr Toff: There are some excellent examples of good practice, where local authorities have ensured there would be specialist public health input directly in the CCGs, for example. That is something other places might want to consider.

Q117 Mark Pawsey: Do you feel that will not happen by 1 April?

Professor Scally: I think that is unlikely at the present time. Every time we go through one of these major reorganisations, we lose about 30% of our senior people in public health, so there are going to be some deficits in staffing. You asked about delay. No more delay, please. On Friday I will be in Birmingham, but maybe not in a leisure centre, it will be two years to the day since the White Paper on public health was published, and we still have not made the transition. There is a good case to be made that this could have been done far earlier, far faster and far more effectively, and the delay has been a substantial part of the problem.

I do think there is a real deficit. When you looked at the initial carve up of the public health budget, exactly the same amount was going to the NHS Commissioning Board as was going to the local authorities, yet there was a very clear but informal view that the NHS Commissioning Board did not want any public health people; they would do it themselves. They are dealing with important issues like screening and immunisation services that are absolutely core public health functions, so I find the whole way in which this has been pursued unsatisfactory in terms of its delay and its fragmentation.

Q118 Chair: We will come on now just to look at where we are up to. Clearly there are different things happening in different parts of the country. Probably not surprisingly, people are approaching things according to local circumstances. How much of a possibility is it that in some places all that will happen is the director of public health will move employees, get a new office and the major issues that people continue to argue about will still be adult social care and who pays for it, and which hospital will close or not close. Is there a real chance that there will be really good examples of public health starting to imbue the whole thinking of the services, and could it even affect the way the NHS thinks as well as local authorities think?

Councillor Steve Bedser: In Birmingham my cabinet responsibility, health and wellbeing, encompasses adult social care, public health and social aspects of housing, so I see the whole as a continuous spectrum. If we are going to solve the really challenging problems we have ahead of us in adult social care, the only rational way we can do it with the resources and system that we have is by prioritising the public-health-type interventions because they are the things that will broadly enable us to have people living longer, more independent lives in their own homes. That is the only way we will be able to make the money work in the long term. I am tremendously optimistic. I do not think any local authority is seeing this as a "lift and shift". I think people are seeing this as a really important cultural change that is taking place across the health and social care economy. Look at some of the self-assessments that have been done with input from the likes of the Local Government Association and regional directors of public health. I am very glad that Penny Toff acknowledged that local authorities were being very conscientious. You will find people who are working very hard to make pragmatic sense. Two years after the announcements of the first notion of change, they are still grappling with uncertainty because there are really key things that are very important to us. How much money is going to be in the budget at the point of transition is something that we need to know.

Q119 Chair: I am sure that there are some great examples around of constructive and original thinking, but are you not already starting to pick up one or two authorities that are probably not getting it right and not doing the right things? You were saying earlier that there are authorities that you would like to step in and help, but if you do not know who they are, or recognise they exist, how can you help them?

Councillor Steve Bedser: The LGA have been doing some very comprehensive self-assessment work. The good news is that 95% of local authorities are in an advanced state of readiness. In any kind of organisational change, to have 95% in a good state is a remarkable finding. That allows us to concentrate resource on the small number of local authorities that are struggling for one reason or another, and bring in peer support and expert support to turn those systems round. I challenge you to look at any other part of public sector delivery where you are having such a high compliance rate.

Professor Scally: There will be great examples of good practice, of course; there already are. A good DPH will not be changing office on 1 April; they will already have been there for maybe the last four or five years. I know in my own region, all but one of the local authorities properly jointly appointed DPHs for many years. My concern is exactly as you put it, however: that the spectrum will widen in terms of performance. I am concerned about the accountability issue. I am not clear how people who are not getting good public health services and function delivered, and whose local authority is not matching up to their future legal duty to improve health, will be dealt with.

In relation to the DPHs, I think they will flourish in local authorities. They have nothing to fear from working with councillors; councillors care about their local populations. That was never an attribute that I saw universally displayed in the executive offices of the NHS. My advice to DPHs has been that they should love their councillors, and my advice to councillors has been that they should love their DPH.

Chair: There is some nodding of heads going on at the other end of the table.

Dr Carter: I have said everything I need to say. This transitional period has a huge risk. Having said that, I still believe the direction of travel is right, and if this is allowed to bed in and mature, in a few years’ time I genuinely think it will make a huge impact in the way that we all would wish.

Councillor Alan Connett: I thought Gabriel put it so eloquently; how could you follow on from that? From our point of view, districts have also seized the agenda. There is a lot to be very confident about in the future. The concerns that have been raised are right and justifiable at this stage, but I think we should step forward and say that local government and the NHS are embracing the agenda with confidence, and I think there is great scope for improvement.

Dr Toff: Your point is absolutely right. There will be considerable variation and it is very important that the examples of good practice are shared. Our concern at the moment is more that some of those directors of public health will not even make it as far as the office, and certainly their staff will not. That public health is everybody’s business is a very clear message that has come out of this, and that has reached most people, particularly councillors and many officers as well. I think the message that it is not anybody’s business-that there might be something very important here that specialist public health has to bring to the table and that has to make it all the way to the council and be retained as an adequate workforce-has not necessarily been heard quite as clearly.

Q120 Chair: One final point, probably for the two councillors most of all. There is talk about public health coming back to local government, but the reality is that in a council like yours, Councillor Bedser, you are chairing the health and wellbeing board. There is not another single councillor on there, as I understand it. Certainly many, in fact, will only have one councillor on there. You may have two or three; I do not know. The reality is that most councillors will not feel any personal commitment to a function that they are not responsible for making decisions about. They may know that there are some extra people who have come to be employed and that public health is something they generally do, but it is not going to be seen as one of the things they are accountable to the electorate for as individual elected councillors.

Councillor Steve Bedser: Just to factually correct you: we have three councillors, and very deliberately we have the cabinet member, me, who has a broad responsibility for adults. The vice-chair is the cabinet member with broad responsibility for children, and we also have an opposition member to ensure that it is embedded on a crossparty basis. We took power in Birmingham in May. I saw public health transition come in a couple of years ago, and I actually made it my business to signal to our leader that this was the portfolio that I wanted. I wanted it on the basis that it was the portfolio that had public health responsibility, because I have got such vision for discharging that duty.

Q121 Chair: Has that translated through to the rest of your colleagues when they are looking at budgets and all the problems they have got?

Councillor Steve Bedser: There is nothing more socialist than caring about poor people dying 11 years younger than rich people. I have found it to be a compelling narrative with my colleagues. When I start talking about public health in terms of helping poor people live longer lives of greater quality, it is something that my colleagues understand very readily and get very passionate about.

Councillor Alan Connett: I think there is a very real job for the local government sector to do in terms of teaching councillors. Every year, the director of public health publishes a darn good report about the health inequalities in the area. I think the change will enable councillors, for once, to ask the pertinent questions of why this is happening in their area and what the health and wellbeing board is doing about it. I think local government, the District Councils’ Network, all of us, need to seize that and empower local councillors, because this for once is opening the gate to them to be able to ask and hold to account.

Chair: Thank you all very much indeed for coming and giving such interesting evidence. Thank you very much.

Examination of Witnesses

Witnesses: Caroline Abrahams, Director of External Affairs, Age UK, Richard Blyth, Head of Policy and Practice, Royal Town Planning Institute, Andy Murdock, External Relations and Policy Director, Celesio UK, and Paul Woodward, Chief Executive, Sue Ryder Care, gave evidence.

Q122 Chair: Good afternoon and welcome to you all. Thank you for coming to give evidence to us this afternoon. For the sake of our records, could you indicate who you are and the organisation that you represent?

Andy Murdock: I am Andy Murdock, External Relations and Policy Director for Celesio UK.

Caroline Abrahams: I am Caroline Abrahams. I am External Affairs Director at the charity Age UK.

Richard Blyth: Richard Blyth, Royal Town Planning Institute.

Paul Woodward: Paul Woodward, Chief Executive of Sue Ryder.

Q123 Chair: Right. There have been great arguments around the Health and Social Care Act 2012, not least in this place, where long hours have been spent debating it. Much of the argument was around what might be called the health side of commissioning of health services. Was social care an afterthought-something that was tacked on or not really taken as seriously as it should have been? Or, when we see what happened with that Act, and then the draft Care and Support Bill coming along, could that actually be seen as the first step towards full integration of health and social care?

Paul Woodward: It obviously would have been better if the health and social care reforms had been carried out in tandem with the draft Care and Support Bill. There has obviously been quite a lot of focus on funding to date, and I think we need to widen that debate to the whole system. There is also the question of what social care is. I think there is a danger that social care is about older people and dementia, and yet from where Sue Ryder sits we are looking at a whole cohort of people with neurological conditions-over a million people who require care-and they live in the system for a very long time. They are often younger people, and with greater needs that span health, social care, housing, transport, welfare, and so on. Often their carers require that as well. So there are very different requirements, and a need for a very holistic approach.

Caroline Abrahams: I will have a bash, then, as well. Clearly, the two were not fully integrated in that piece of legislation, and they are not quite in parallel. The other thing I would say about that is that-depending on your time frames-it is not as if we are only now just starting to think about how better to join up across health and care. People have been at it for an awfully long time. A lot of people have been working hard on the ground to try to achieve this, before the Act came in. There is a bit of a longer term history, and the message from that is: if it was easy to do, it would have been happening already. There is quite a challenge for us.

Of course, I agree with my colleague Paul that social care is not just about older people. It is importantly about older people, but we are a member-and I think Paul probably is, too-of the Care and Support Alliance, which has over 70 organisations all working together. This encompasses both organisations working with adults of working age and with older people, all of whom think care is really, really important. In a way, the things that bind us together are a bit more important than the slight nuances of difference on the detail. We all agree that care is really, really important and needs to be joined up properly with health.

Andy Murdock: That one might be a university thesis question. Actually, does it really matter now? We are where we are, and we have just got to make it work. The social care aspect of it, with health, is a great opportunity for that if it is the first step on the road for that integration. I think that is massively important, irrespective of how we define that. Obviously, in the parochial pharmacy area from which I come, there are elements of care that we can give within the home, which is not the same type of care as other people give. I think it is a golden opportunity to take that care pathway and lock social care into it in its holistic form, and drive it forward. I think it is a massive opportunity.

Q124 Chair: Does it ultimately need someone to be responsible for it?

Andy Murdock: Yes, we do need somebody to be responsible for it, absolutely. That is going to be part of the challenge that we have got on the potential fragmentations of the system. Potentially, if you go from four levels of authority in the NHS pre-change to the numbers that we have got now, you think, "Well, how are these going to work together?" That clarity of how they are going to work together, and the communication between the organisations, is going to be absolutely key. I do not see that clarity at the moment. Perhaps it is still being worked through on the ground.

Richard Blyth: I am hopeful that, coming at the same time as the transition, the ability of the health and wellbeing boards to consider things like transport in relation to social care and housing together-rather than have different subjects being operated in isolation-will be a step forwards.

Q125 Simon Danczuk: Health and wellbeing boards are exceptionally important bodies, set up and determined locally. Is that going to make your engagement with them more or less effective? Is it going to make it easier or harder? Caroline, we will start with you. What do you think?

Caroline Abrahams: Engaging with health and wellbeing boards as a voluntary organisation? We have 170 local Age UKs, and, to be honest, they are finding it quite tricky to engage at the moment.

Q126 Simon Danczuk: Why is that, do you know?

Caroline Abrahams: All sorts of reasons. It is partly because, obviously, there is a lot of change going on locally across the NHS and in local authorities. A lot of all of this is based on relationships. Sometimes people are finding the people they knew have moved on to other things. Also, because health and wellbeing boards have a huge job to do, and lots of different interest groups are all badgering for attention, it is quite hard looking at it from the other end of the telescope. It is probably quite difficult for health and wellbeing boards to know how best to engage a very disparate sector. Some are doing it very well. Some are setting up subgroups. We are, frankly, just as interested in the health and wellbeing boards reaching out to older people directly as we are interested in them talking to us, for example. We can help facilitate that, but just as important are all those engagement mechanisms that they need to put in place. Some are doing a good job.

Q127 Simon Danczuk: Paul, do you have a view?

Paul Woodward: Yes. Like Caroline, I think we are finding it quite patchy. In some areas we are very heavily engaged, and in other areas we are not engaged at all. For instance, in Leeds we are talking with them at a strategic level about how to develop things. But I suppose, in a way, what we do not know is what we do not know. Where we are not being engaged, it is very difficult to figure out where that is coming from. We are finding that within local councils they are able to seek expertise on the boards, particularly where they do not have health representation. It is encouraging to see that the leaders of some councils are taking up the chair of these positions. Whether that is sustainable long term is difficult to say. We are trying to engage with the local Healthwatch organisations, and again, that experience is quite patchy. We are hopeful that over the course of the next year we will start to see some real change going on.

Q128 Simon Danczuk: Richard, your organisation’s submission said that planning and transport authorities’ officers needed training in how to effect and create dialogue with health and wellbeing boards. Is that right?

Richard Blyth: Yes. There has been a lot that has been going on on that score. A useful initiative came out recently from the Town and Country Planning Association about reuniting health and planning professionals. You have been hearing in the previous session about the question of tiers and whether district council services are going to be satisfactorily represented on the boards, so I will not go over that. I worry to a certain extent about how different health and wellbeing boards relate to each other. We are very concerned as a profession about how you deal with the larger than local considerations in local government as a whole.

If I give a theoretical example: if you have an area where chronic overcrowding is a problem and you have not got the land within your area to sort that out, and you are a unitary authority or a county, how do you then influence the health and wellbeing strategies of the neighbouring area and its board? That is possibly an issue over neighbourliness and over space, which may not have perhaps been the focus of other people’s evidence before you. I think it is a very important question, and one where my members are going to feel that there is a need for some kind of mechanism for the cross-boundary health and welling board issues to be considered.

Q129 Simon Danczuk: The NPPF will sort all of that, won’t it, Richard?

Richard Blyth: Well, it will in relation to planning. I suppose the question is how that relates to how the health and wellbeing boards themselves work and the public health agenda, and also particularly the way in which the CCGs function.

Q130 Simon Danczuk: My second question is about the joint strategic needs assessment, which is pretty crucial. I think you were moving towards this, Caroline, in terms of how you consult, involve people and gather information. What do local authorities need to do to improve this aspect of their role-gathering all that information-do you think?

Caroline Abrahams: Lots, actually, to be quite honest. Firstly, getting beyond the jargon and being able to have transparent data available locally so that providers and others can use it as well, and presenting it in a way that is relatively jargon-free, would be a good step forward from the point of view of encouraging engagement. Secondly, getting beyond the numbers to understand attitudes and what drives local behaviour, for example, in our context, amongst older people, would also be very important. To give you an example, we have an initiative at the moment called the Cost of Cold, which is all about trying to reduce the numbers of excess winter deaths amongst older people. We know that there are a lot of older people who do not understand that the cold is a very real risk to their health and even their survival through the winter months, and they do need to take extra steps to wrap up warm. We have got all sorts of things going on to try to support that through volunteers and so forth, but there is also a big issue there for health and wellbeing boards and local authorities more generally.

Ensuring that local authorities and their colleagues are able to understand that, and find ways to engage with it and communicate properly with groups in the community, would be quite a good place to start. Clarity of communication, good use of transparent data, and making sure that it is kept up to date-because, of course, things change quite quickly in lots of areas-would all be a good start with the JSNA.

Q131 Simon Danczuk: Paul?

Paul Woodward: We are often seeing a focus on what they do know, rather than what they do not know. We published a report, The Forgotten Millions, a couple of weeks ago. As part of that, using the Freedom of Information Act, we asked local councils what provision they were making for people with neurological conditions. Only 10% of those councils have an agreed local commissioning strategy for people with neurological conditions. Only 5% knew exactly how many individuals with any neurological condition they care for, and only 6% categorise and collect data on people they care for with specific neurological conditions. Now, that is pretty poor. If we are talking about people who are in the system for many, many years, it is not just about planning for the needs of today. It is about planning for the needs in five years’ time and in 10 years’ time. Without good data, you are not going to get a good strategy, and without that strategy you are just going to get a fairly scattergun approach. For us, data collection is a real concern, particularly for people with neurological conditions. Obviously, the joint strategic needs assessment is the vehicle by which that data can be collected.

Where you do see best practice, the local authorities are collecting data from health; they are collecting data from social care; they are collecting data from charities; and they are pooling that information together. That is what we should expect to see across the whole country. Neurological conditions are very, very complex in nature. Broadly speaking, you can characterise them as relating to either a cognitive or a motor capability, so somebody, for instance with multiple sclerosis will go down a trajectory of motor capability as that disease progresses. Somebody with dementia will be very mobile, but will have cognitive issues. Then we also have the added complexity of people who have both cognitive and motor impairment: people with Huntingdon’s disease, acquired brain injury, and so on. There cannot be a "one size fits all" in terms of developing that strategy. It has got to take into account individual needs.

Q132 Simon Danczuk: Andy, I read that your organisation had raised concerns about pharmaceutical needs assessments. Are they now being included in health and wellbeing boards’ joint assessments?

Andy Murdock: They should be, but the challenge is not only their inclusion; I would argue for their mandatory inclusion, which should form a data set for the JSNA to be founded on. The challenge is also the quality of those PNAs. They first started to be formed back in 2009 or 2010, and the first tranche of those that came out were of variable quality. There is the essence of that, because one of the aspects at which PNAs should be looking is the improvement of access to health and wellbeing, and pharmacy’s ability to do that. It is absolutely crucial to make sure those PNAs are in the JSNAs, have good quality, and-as somebody has already said-are updated in a timely manner.

One of the challenges that pharmacy will have in that respect will be that health and wellbeing boards do not really know pharmacy as a channel access for the distribution of public health in the way it should be. Pharmacy, historically, has never really needed to engage with the local authorities. It has always been with the PCTs in that respect. That is a fantastic opportunity, because there are some good delivery mechanisms there.

Q133 Simon Danczuk: Yes. Richard?

Richard Blyth: There is some good news on JSNAs. You mentioned the NPPF: for some time before that came out, my profession was encouraging its members to get thoroughly involved in the process, although it was originally seen as a health thing. The health and planning interface is a lot healthier than the education and planning interface, where there is not the same commitment to a joint evidence base. There are things to celebrate about the JSNA process.

Q134 Simon Danczuk: One final quick question: do you think there is going to be an issue around information sharing or concerns about data protection-you know, sharing information that enables different agencies and bodies to work together to solve the person’s health and wellbeing issue? Any issues around that?

Paul Woodward: I am not aware of any data protection issues around that, because I am not an expert in that area. Obviously, it is really important to collect this data and data from diagnosis. Health data really needs to be plugged in, because you cannot do any serious planning if you do not know what is coming down the track. At that diagnosis phase, it would be really useful.

Andy Murdock: This is not from a data protection perspective, but actual access to a comprehensive record is absolutely key. If we have various healthcare professionals working across various levels and channels, we need to know what that continuity of record looks like. At the moment, that is pretty hard to get hold of, so that would be my plea if anything else.

Caroline Abrahams: I think much of the data they will need will be population level data, which will be anonymised, so there should not be a problem with that. With more niche areas, it might become more problematic. Although in principle, as I understand it, there is no reason why data protection gets in the way of that, we know there are still lots of myths around between different professional groups-particularly on the front line-about what can be shared and what cannot be. We would be wise not to assume that it is all done and dusted. There may still be some more clarity and really clear messages needing to go out about that.

Q135 Mark Pawsey: Chairman, in our previous session we spent some time talking about setting objectives and identifying outcomes. I am just wondering if you could tell us your views about constitutes success at this, and in particular, Mr Murdock and Mr Blyth, how your bodies can contribute to improvements, particularly in the areas of public health.

Richard Blyth: I am conscious of the contents of the domains of the public health outcomes framework. We note that, although they are described as the wider determinants for health, there is not a reference to overcrowding and housing as a measure. If we were to have another one when the current framework expires, there might be a question there, because there has been this concept of returning public health and local authorities to their 19th-century roots. In both the public health profession and my profession, there has been a long­standing understanding of the relationship between housing conditions and health, which are currently quite poor in some places. It is interesting that, although it is an outcomes framework, the first domain is about the things that cause ill health rather than the outcomes. There is a question there about possibly measuring the housing aspect of it, and also, maybe, the worklessness aspect that currently only comes under the NEET area. It is young people’s worklessness, rather than overall. From my evidence, also, there is the whole question of the health of places: so if you really are living in a place that has got no town centre to speak of at all, will there not therefore be some kind of connection to public health outcomes as well?

Q136 Mark Pawsey: In your representation, you argued very strongly for returning healthcare services into town centres. Why is that so important?

Richard Blyth: There are two clear reasons. One is that it is important to give people access to healthcare. If it is in locations you can get to only if you have your own car, that either requires having to ask people to take you, or complex taxi or bus arrangements. So there is an "access to the care" aspect. There is an issue in terms of take-up. I have this vision of a drop-in wellness centre in the middle of the high street, next to the sandwich shop and the place where you go and get your salad at lunchtime, to encourage take-up of the kind of public health preventative services that are so important to get, particularly among busy working people. If you could do that in a town centre rather than having to make a complicated trip somewhere, even if you have access to good transport, and you have got the opportunity to do a dual function-you can deal with your health and also your sandwich-then that makes it quicker.

Q137 Mark Pawsey: If we accept that that would be a good thing, how would you go about measuring that? Is it not completely peripheral and on the edge? It would be a nice thing to happen, but how are we going to say there are health benefits from doing it? I may ask you: how are we going to implement it? How are we going to achieve it?

Richard Blyth: A number of PCTs in the past have tried to maintain standards about the travel time to GP surgeries, for example. My slight worry about the transition and the new arrangements is who is going to be responsible for maintaining, say, a high standard of accessibility? It is quite possible to measure that-you can say how many people are within 10 minutes’ walk or 800 metres of their GP surgery-but who is going to be responsible for continuing to ensure that that is maintained? That will hopefully be something that will come to the local authorities along with the health and wellbeing boards.

Q138 Mark Pawsey: Mr Murdock, what input can pharmacy have?

Andy Murdock: I can solve the access point. That is not an issue.

Q139 Mark Pawsey: How?

Andy Murdock: There are 11,300 pharmacies in England, and you will see that the distribution of those will go from local communities right through to town centres and retail parks. Therefore, the community pharmacies have a fantastic opportunity to spearhead some degree of public health and wellness-type activity. If you take the access data in that respect-DH figures, I appreciate-they reckon that 99% of people have access to a pharmacy within 20 minutes by car, and it is 96% if you go by public transport. That access is there to a point. To come back to your question of how we look at it and what is on offer, rather than go through it now, I can send in some data if the Committee wants. There is stuff around how pharmacy has contributed to sexual health and has had-from our perspective-better chlamydia detection rates than the national programme. There is stuff around diabetes, blood pressure, NHS health checks, and a great study from the Isle of Wight on flu vaccination programmes. Pharmacy has delivered on that.

The interesting concept is possibly a concept called Healthy Living Pharmacy, of which some of you may or may not be aware, which started out of Portsmouth. It took about 17 pharmacies and trained the staff up as healthy living champions, so they promulgated healthy living and wellness. There were some leadership skills put in that, and then they ran a number of services, including smoking cessation, I think some sexual health ones, and minor ailment services. They did 23% of the quit rates of Portsmouth. Now, that Portsmouth model has been taken and it has been distributed across the UK. There are about another 100 pharmacies across the UK that are now being evaluated to see if the Portsmouth study can be uplifted and put across the rest of England. We are waiting for that data to come out now. I am not expecting that to be adverse, and I think that would be a good mechanism.

Q140 Mark Pawsey: How would you engage with health and wellbeing boards, then, to bring forward those health improvements?

Andy Murdock: It is around us being able to get into the health and wellbeing boards. If the health and wellbeing board wants to commission, they set up services, be it smoking cessation or sexual health.

Q141 Mark Pawsey: Do you have enough access to those bodies now?

Andy Murdock: No.

Q142 Mark Pawsey: You would like to be closer to them?

Andy Murdock: We would love to be a lot closer to them. At the moment, as somebody mentioned, there is a lot of focus-which you also see with commissioning support units and other parts of the restructure-on a lot of internal stuff being sorted out, and just getting the things up and running and operative before we actually go out and talk to some of the other bodies. Yes, I would love to be talking more with the health and wellbeing boards.

Q143 Mark Pawsey: Do our other two witnesses have views on how we should be going about measuring some of these very difficult concepts, so that we can actually establish that we are going in the right direction?

Caroline Abrahams: Sure. With any group, it is quite useful to start by thinking about what they think good would look like. When we asked older people "What does wellbeing mean to you?" they mentioned five things: positive frame of mind, a balanced diet, keeping active, mental stimulation, and social contact. If you translate that into a public health context, that suggests it would be important, for example, to measure levels of participation and contact by older people, and not to look just at, for instance, by how much we have managed to bring down the number of smokers over the last period.

Q144 Mark Pawsey: How would you manage that content? Who would do it? How would you do it?

Caroline Abrahams: I think you could do that by surveys, to be honest. You could certainly do it by working with and through voluntary sector organisations. While the direction of travel of many of these reforms is very welcome, given that they are happening at a time when resources have never been tighter, one of the messages back to health and wellbeing boards and local authorities is that they have got to sweat every local asset that they possibly can in order to make these reforms work as well as possible.

Q145 Mark Pawsey: On that point, would you argue that the tightness of the Government’s spending framework means that, if someone comes forward with an idea that is perhaps radical or rather different, local authorities are less likely to implement it? They will stick with what is safe and what is sound,

Caroline Abrahams: It could work either way, to be honest. Some people would say that, when things are really tight, it forces you to think much more creatively. There is a kind of happy medium around all of that. One fears that in other areas-and we have seen, of course, a degree of salami-slicing, which we may be talking about a bit later-just at a time when you would want lots of those cheap, low­level support services to be operational as one of the mainstays of any kind of local health and wellbeing strategy, they are coming under real pressure. That is because councils and others are feeling that they just cannot prioritise them. Some are, but very many are not.

Q146 Mark Pawsey: Mr Woodward, would you agree with Caroline?

Paul Woodward: Yes, I do, indeed. Obviously, our service users are somewhat different. We have a younger age group: in fact, last year we published a report through Demos called Tailor Made which looked very specifically at these outcomes issues. Our service users do not tend to see their lives in silos. They see things as just wanting to achieve broad outcomes: so maintaining their independence, being able to spend time with family and friends, and also being engaged with the community.

Q147 Mark Pawsey: Are you happy that there are measures of those kinds of things, and that surveys will bring the answers forward that will tell us whether or not a set of policies are taking things in the right direction?

Paul Woodward: You could certainly look at that through surveys, yes.

Q148 Mark Pawsey: Is that the only way? Are there other ways?

Paul Woodward: No, because it is about the quality of life that our service users with neurological conditions are actually enjoying. What is a good outcome? It will be those things: maintaining their independence, engaging in their local communities, spending time with family and friends. These are just broad things, which I cannot see any way of measuring other than asking people whether they are actually getting it or not.

Q149 Bob Blackman: Just moving on to some financial issues, if I may, the King’s Fund, in their evidence to us, suggested that there is an imbalance between social care funding and NHS spending that is coming in. That, potentially, could skew where money goes and how it is spent. Do you think there is an opportunity here for better integration of social care funding and health funding? Paul, in your evidence, you have given a very strong view that this could be a huge opportunity.

Paul Woodward: Absolutely. There is no doubt that if you join health and social care together, then you should be able to get funding reductions. We see all sorts of instances, for instance, where people are kept unnecessarily in hospitals because they cannot be discharged into their communities.

Q150 Bob Blackman: Because there is nowhere for them to go?

Paul Woodward: There is nowhere for them to go. We had an incident, in fact, last Christmas, where somebody was admitted to one of our hospices. Their continuing care funding was cancelled as a result of their being admitted. Our interventions took place, and this gentleman was able to go back into the community, but that could not be done because his continuing care had been taken out. That sort of thing happens as well when people are admitted to hospital, so if you do join the things up, you can take money out of the system.

Q151 Bob Blackman: Okay, thank you. Richard?

Richard Blyth: We cite an example of a social enterprise in Bromsgrove. I think I have got seven bullet points of the different under-contract activities they are undertaking, such as mental illness reablement; intensive breaks for the carers of very disabled children; stopping smoking; healthy lifestyles; and youth work. The fact that one social enterprise is able to perform all of those functions does lead to some internal economies of scale for them. Also, it is not just town centres; this is located in a formerly abandoned shopping parade in a largely affordable housing estate, so that is reinvigorating what was previously a dying district centre. Because one organisation is undertaking a number of parallel contracts, there are these spin-off benefits, which it is good to have in addition to the ones that you are formally measuring in order to make sure that you have delivered your service.

Q152 Bob Blackman: Okay, good. Caroline?

Caroline Abrahams: Yes. I think that we are all going to agree here.

Q153 Bob Blackman: But I have got a sting in the tail for you.

Caroline Abrahams: Okay. Just to give you an example, in Cornwall we are trialling an integrated care pathway, as they call it in the health jargon. That is a joint approach among Age UK, local GPs, the local authority and all the local health bodies, and is trying to work out what you can do in terms of prevention and early intervention with older people at risk of sudden admission to hospital because they are frail and they are not otherwise getting the support they need at home, and then helping them to make a good recovery afterwards. The whole point of that scheme is that we are going to trial it using a social impact bond. The theory behind the social impact bond is that you can extract cashable savings through that kind of approach, because you are essentially saving the cost of keeping older people in hospital, which I think is £250 a day. That adds up pretty rapidly, as you can imagine. Therefore, that cashable saving goes back to your original social investors. Now, who knows whether we will pull that off, but it will give us a very good example.

Q154 Bob Blackman: One of the clear concerns for your organisation surely has to be that a lot of the emphasis is on sexual health, children’s services, etc, which tend to be aimed at younger people. How are older people going to get a fair deal out of this, particularly when local authorities may start stretching the envelope, and saying "Well, a bit more investment in leisure centres," and goodness knows what else. It is all good for the health of the locality, but how do older people get a fair share?

Caroline Abrahams: You are right to point to the concern. Obviously, there are lots of different groups, and health and wellbeing boards are being asked to do an awful lot of different things all at once. I go to lots of meetings where people say, "That is okay; the health and wellbeing boards are going to do that." After a while, you begin to think, "Hang on a minute; if that is always the answer, that is telling you something about the expectations on these groups." Ageing well is one of the strands of activity that the health and wellbeing boards are required to look at, so from that point of view we are pleased to have a hook.

I think the truth is that, as Paul was saying in his opening remarks, the backdrop for many local authorities-and, indeed, for local NHS bodies-is the knowledge that we have an ageing population and that that is a big call on health and care services, and the realisation that we have to work differently to meet those costs and sustain good quality services. The context is there, and the knowledge that these things now are high priority is there, but how you do that alongside everything else is a really tough question. Traditionally, older people have not been a central focus of public health activity. We need to get those messages across that it is never too early for prevention, but it is also never too late.

Q155 Bob Blackman: Some of the evidence we have heard-for example, earlier this afternoon-suggests that not enough money is being spent on public health and not enough money is going into local authorities. So, given all of these other competing priorities, how are you going to make sure that older people do get their fair share?

Caroline Abrahams: Organisations like ours will be jumping up and down locally and nationally, as you can imagine, because that is our job.

Q156 Bob Blackman: I am sure you will, yes.

Caroline Abrahams: But, of course, so will our colleagues representing other groups. I think you are right. It is such a shame that the right thing is happening at a time when the trend in the resources is going in the opposite direction. With the best will in the world, it is going to be hard for health and wellbeing boards, but, as all our answers have explained, there are also potential ways of working differently to make more of the resources that are around.

Q157 Bob Blackman: Andy?

Andy Murdock: I concur. There is a question-almost a rhetorical question-that I have not yet come across the answer to. Again, from earlier in the afternoon, there is a £2.2 billion budget that is historical transfer, and you have intimated "Well, is that right?"

Q158 Bob Blackman: I do not think anybody knows.

Andy Murdock: Has anybody done that analysis? What concerns me is, if the view is that we should be moving to more public health and preventative­type care, I do not necessarily see that tide moving massively. We talk about it, but I do not see the tide moving massively, and therefore the cash that goes alongside it. Has anybody done that analysis? I suppose it is a bit like a Wanless-type review for public health. I know Marmot did it, but have we got a cash analysis that sits there and says £2.2 billion is the right figure or not?

Q159 Bob Blackman: The BMA suggest, for example, that all public health funding should be signed off by the director of public health in the area. Do you think that is the right level, or should we devolve down further?

Andy Murdock: It depends how you classify what public health is at that point.

Q160 Bob Blackman: For example, if it is the whole budget that is dedicated to public health in the area, should it be signed off at the director level or should it be devolved to particular areas within that bigger area?

Andy Murdock: Ultimately the activity within those sub­areas-if I can use that terminology-will be determined by the JSNA and the joint health and wellbeing strategy. Once that is signed off, and the director of public health buys in to that strategy, then, to me, it is a devolvement down to that particular level.

Q161 Bob Blackman: Richard, do you have any concerns that people representing housing and housing bodies do not have an automatic right to be on these health and wellbeing boards?

Richard Blyth: I concur, to a certain extent, with the views expressed by the District Councils’ Network, in the sense that services provided by district councils are very important in the social determinants of health. I also recognise that, if you have got a county with 14 districts, you are not going to have 14 districts around the table. I understand that, in evidence put to you, there have been examples of the ways in which districts have clubbed together to make a single voice in two­tier areas. It is not necessarily just a housing question: it is a question of the whole function of district councils. In some large areas where, for example, the council has become unitary, one of the bases on which unitary county councils were set up was partly a compact saying, "If we have a unitary county council, we will do a lot more devolvement of decision making." Arguably, that same model could be used in relation to the question you posed, as it has already been used by some of those large unitary county councils already.

Q162 Bob Blackman: An argument could be put that people suffering multiple deprivation frequently are in social housing, and yet the landlords of that social housing-be they housing associations or authorities-do not have an automatic person on the health and wellbeing boards. These are the very people that have the severest inequality in terms of expectancy. Should they not have an automatic right to be there?

Richard Blyth: It is difficult to say, because of this whole question of the size of the board and the area they are covering. I do not have a view about whether I would definitely say that housing should have an automatic seat.

Q163 Bob Blackman: Any other views? Paul, you were nodding.

Paul Woodward: I think they should. Certainly, people living with neurological conditions will have some housing need at some point, and therefore the sooner that is plugged in, the better. I can give you an example of somebody we care for with multiple sclerosis who waited for four years to get appropriate housing. Of course, because she has a degenerative condition, she now cannot use the house that she is in, so she cannot use the stairlift and get upstairs. She has now converted her dining room into a bedroom, and the only sanitation is an outside toilet, and she has to have her clothes removed in the house before going out to this thing. All the while, the local council and the housing association are arguing as to who should pay for any sort of conversion. After many months of arguing, it has been decided that she is going to have to be moved anyway.

Q164 Bob Blackman: The only drawback of that-and I have every sympathy with that specific case-is that it is a specific case, and the health and wellbeing boards are going to be looking at the generality of spending and not necessarily specifically.

Paul Woodward: But it is symptomatic of not plugging housing in when you are looking at the overall needs of somebody with a very complex condition, and so the earlier that is put into the equation and the greater understanding that the health and wellbeing boards have about very complex conditions, the sooner they can start planning.

Richard Blyth: There certainly might be a case for saying that, although housing is not in the national outcomes framework, it may be that local areas might wish-in terms of the strength of feelings expressed tonight-to include it in local outcomes.

Q165 Bob Blackman: Caroline, any concern for the elderly?

Caroline Abrahams: We said that we thought housing should have an automatic seat at the table, but representation on these boards is not everything. I think it is also open to boards to set up other arrangements for ensuring that really important issues get the airtime that they need. We certainly know of one or two that have set up specific subgroups of people to look at the importance of housing, and that is another way in. What matters is the priority they accord to it. We totally agree that it is a very important issue.

Q166 Bob Blackman: Andy?

Andy Murdock: No. Nothing further to add on that.

Bob Blackman: Fine. Thank you.

Chair: Thank you very much for coming to give evidence to us this afternoon.

Prepared 26th March 2013