The role of local authorities in health issues - Communities and Local Government Committee Contents

4  Public health in practice

Tackling the causes of the causes of poor health

82.  We have described the new arrangements for the promotion of health and wellbeing and for the integration of health, public health and social care. We have also examined the means by which local government and its partners in local and national health, in the community sector and among providers might assess residents' needs and create strategies to deal with them. These organisational matters will be important, but the approach that councils and their local health partners take to public health will be critical. It will not be enough for one "public health" department in isolation to commission services to deal with single issues such as obesity or smoking. Councils will need to focus all their policies and services on the social determinants of health—the social, economic and environmental reasons why people experience ill health or develop unhealthy behaviour—if they are to make an identifiable difference to the health and wellbeing of their residents. In this chapter we consider what this should mean in practice and how the impact of their work might be measured.

83.  Neil Blackshaw, of Easton Planning, a consultancy with major public sector clients, explained, "The English health system has been dominated by the medical model of health throughout the evolution of the NHS."[184] In contrast,

the [social determinants of health] model states that a person's health status is a function of their social, economic and environmental situation […] The failure to espouse this model wholeheartedly was the result of a combination of silo working and professional resistance and it has contributed to the persistence in inequities.[185]

84.  Dr Nicholas Hicks, Director of Public Health in Milton Keynes, was concerned that despite public health functions moving over to local government, some local authorities might not recognise the way in which those functions could then be integrated with the council's existing responsibilities and services:

There is still a risk that too many people see public health as just preventive services, health improvement or health protection and do not necessarily see the whole strategic content […] does the council really get its role as being the leader and responsible body for health in its community?[186]

Dr Mike Grady, principal adviser at the UCL Institute for Health Equity, agreed and raised the issue of resources:

early years education, our young people who are unemployed and not in training, our people who need support […] and our older people […] that kind of spend needs to shift into a public health agenda rather than provision (of specific public health services).[187]

He wanted to see an approach that went beyond "just … commissioning" to one about empowering communities and creating greater social cohesion. He said that "the primary driver needs to be the empowerment of individuals and communities, and then a range of support services and commissioned services support that activity."[188] We saw on our visit to Kent an example of integrated services in Gravesend town centre at the Gr@nd Healthy Living Centre, which incorporated services such as smoking cessation, a job club and youth counselling. We heard that such integration, currently taking place at one community centre, would need to be expanded by a local authority throughout its area and across its services. Sheffield City Council described this as the "place-shaping capacity of councils",[189] and David Buck, from the King's Fund, told us that

the Marmot review has been working quite hard with lots of local areas to try to embed its overall high-level policy-type advice in to what this can mean locally. I know the LGA is also working on this agenda […] One of the critical roles is to make this meaningful for local decision makers.[190]

Professor Chris Bentley, an independent population health consultant, referred to this approach, which he described as a "whole system approach", in relation to alcohol-related harm, telling us that it might include:

Population level inputs: licensing; bylaws on street drinking; controls on advertising; enforcement of trading standards/sales to minors;

Community level inputs: extended school education programmes; health trainers; community lifestyle initiatives; health champions

Service level inputs: Tier 1 - 4 alcohol services; social care wraparound services (debt management; housing support; job support).[191]

Dr Grady was confident that local government was "grabbing hold of this agenda", and was not "being dragged back … into lifestyle initiatives"—commissioning, for example, one education campaign to tackle one health issue, such as smoking. He said such initiatives "do not work and certainly do not work in the bottom 50% of the social gradient of health".[192]

Examples of local authority initiatives

85.  Witnesses gave us examples of how they hoped to use such an approach to begin to shape the conditions in which people live. On the example of dealing with alcohol-related harm, Newcastle City Council said that

instead of simply looking at alcohol treatment services, which is dealing with the problem too late, we are looking at the environment in which people think about and consume alcohol. That includes looking at the availability of it through not just pubs and clubs but also off-licences.[193]

On another health issue, obesity, Sheffield City Council explained that

we also want to look at some of our by-laws to see what we can do in terms of where food outlets are placed: are they near schools? Do we want some food outlets, takeaways and so on, in certain places?[194]

86.  Decisions on appeal by Planning Inspectors have shown that in order successfully to refuse planning permission for a takeaway on the grounds of proximity to a school and the existence of a school's healthy eating policy, a local authority must also point to an over-concentration of takeaways in a certain area and to evidence of a link between childhood obesity and their proximity to schools.[195] Several councils, such as St Helen's, have now published supplementary planning guidance relating to takeaway establishments, putting in place a clear policy to exclude them from a certain distance around schools.[196]

87.  In early January 2013, Westminster City Council and the Local Government Information Unit, in a joint report on the role of councils in public health, proposed several ways in which local authorities might embed healthy behaviour in their communities. One suggestion involved a link with welfare:

Relocalisation of council tax benefit [...] combined with new technologies provide an opportunity for councils to embed financial incentives for behaviours that promote public health. The increasing use of smart cards for access to leisure facilities, for instance, provides councils with a significant amount of data on usage patterns. Where an exercise package is prescribed to a resident, housing and council tax benefit payments could be varied to reward or incentivise residents.[197]

BMA member and GP Dr Lawrence Buckman called the idea "draconian and silly": "The best way [councils] can intervene is to stop restaurants and fast-food chains providing the kind of food that make people put on weight, and interfere with the way foods are sold in shops."[198] The Westminster City Council and LGIU report, however, did include the proposal:

In areas identified as food deserts, where fresh and affordable foods needed to maintain a healthy diet are unavailable, councils could offer incentives to local shops that make such services available through social investment funds.[199]

When we asked Professor Chris Bentley for his assessment of the idea, he told us, "if they [Westminster City Council] are saying, 'We have a range of other things we can do to support you to get yourself in a position where you can benefit from these interventions,' I think that is perfectly sensible."[200] He also suggested, in order to change behaviour across a community, some councils might benefit from more advice: "While central direction is not an option, there is a strong case for better guidance and developmental support on what will be needed to achieve population level change".[201] When we put this point to the Health Minister, Anna Soubry MP, she cited smoking and how local authorities, "under the guidance of PHE, who can provide statistics, advice" etc, could identify a local ward's incidence of smoking and then make a local decision to target smoking. In this way, she said, local councils could then "apply an order to make children's playgrounds no smoking areas […] work with the local school […] and […] make sure that all the pharmacies have got the right gear, that the GPs are stuck in on it and so on".[202]

88.  Local authorities, if they are to grasp fully the opportunity afforded to them by the return of public health, will need to look beyond those services traditionally considered to be "public health", such as health protection, health promotion and disease prevention, and tackle the causes of the causes of poor health, working with local partners and using all the powers, personnel and services at their disposal. The evidence we received makes it clear that people, particularly in vulnerable groups, are more likely to exhibit a range of unhealthy behaviours. Single initiatives targeting individual lifestyle choices, such as drinking or smoking, have been shown not to work, especially among people at the lower end of the social gradient of health. Authorities should be willing to take one step back from treatment to look additionally at by-laws, education campaigns and how to involve, for example, GPs, pharmacies or debt management and housing services in a more holistic attempt to deal with the multiple reasons behind complex health problems.


89.  Sir Michael Marmot, in his review of health inequalities in England, stated, "efforts to reduce health inequalities […] must address […] the quality of early years experiences."[203] The review also noted:

What a child experiences during the early years lays down a foundation for the whole of their life. A child's physical, social, and cognitive development during the early years strongly influences their school-readiness and educational attainment, economic participation and health.[204]

Professor Chris Bentley, agreed, "The key one is about early start, because if you miss children in the first five years of life, when their cognitive abilities are developing, it means they are playing catch-up for the rest of their lives." [205] He was, however, concerned that "Health and Wellbeing Boards seem to be neglecting that."[206]

Other witnesses indicated that HWBs were concentrating on early years interventions. Liam Hughes, the independent Chair of Oldham Shadow HWB, said he would like to "focus on the emotional wellbeing of very young children and also on early speech and language." He added that over "a period of a few years we should be able to see those children more ready for school at age four and a half or five." [207] Dr Mike Grady also pointed out that readiness for school could be measured:

If you look at the figures for Birmingham City Council in relation to readiness for school, what you will find is within three years they shifted that figure from 38% to 55% by having a coherent strategy, agreed joint priorities, integration of services and an absolute focus on what the health outcome was that they wanted to achieve.[208]

Cllr Mary Lea of Sheffield City Council said: "We think it is really important to focus on early life, nought to three, that age group. That is absolutely vital".[209]

90.  Local authorities will of course wish to base their public health work on their Joint Strategic Needs Assessments, but we note how several councils have placed early years interventions—literacy, readiness for school and childhood obesity programmes—high on their list of priorities. We commend authorities to bear this in mind when making their decisions, given the importance of early years development in people's later health and wellbeing.


91.  The connection between work and health was emphasised by Westminster City Council, when it told us of the employment initiatives that it would seek to introduce:

Employment is one of the most evidence based determinants to a person's health and well-being […]. Our Health and Wellbeing Strategy will help people to successfully return to work and retain work by supporting people with health conditions/disabilities and promoting quality work and health and well-being in the workplace.[210]

Such evidence might include a study of increased life expectancy in local authority areas between 1998 and 2007, which found: "Decreases in unemployment and increases in average income in an area explained, to a large extent, why some local authorities 'performed' better than others."[211] In Sweden, the National Board of Health and Welfare (NBHW) told us that it recognised three levels in public health: structural, involving a person's education, participation in society and economic circumstances; environmental, including people's workplaces and their local residential areas, and lifestyle, such as their drinking, eating and exercise habits. Bosse Pettersson, NBHW director, explained that to tackle the lifestyle factors, they had to work through the first two levels, because then they were able to see the connection between, for example, unemployment and smoking.

Cllr Nick Forbes, leader of Newcastle City Council, told us that his authority would focus at least some of its work on unemployment,[212] and Cllr Mary Lea, from Sheffield City Council, said:

We would like to see maybe more powers devoted to local government so that we can tackle more of the social determinants of poor health and inequalities. In particular, maybe we are looking at the Work Programme. That may be something that we would like to see devolved down to local authorities, because we think we can maybe make a better job of that than is currently happening.[213]

In our report, Localism, we noted how the Government's definition of the concept was sometimes stretched and contradictory, and concluded:

Some policy areas appear to have been granted an exemption from decentralisation. The priorities of the Department for Work and Pensions appear particularly resistant to the arguments for devolving power to local institutions, despite the eagerness of local authorities to be more involved in shaping the response to worklessness in their area.[214]

The Under-Secretary of State for Communities and Local Government, Baroness Hanham, pointed out, however, that on employment initiatives local authorities "already take that responsibility […] supporting apprenticeship schemes and looking after people that are not well, and encouraging them back [to work]".[215]

92.  We are pleased that local authorities are looking at the evidence and adopting an evidence-based approach to health and wellbeing. Evidence shows that being and staying in work has a significant effect on a person's health and wellbeing; unemployment is one of the causes of the causes of poor health. It follows that a strategy to combat worklessness might be one of their public health initiatives from April 2013. This requires the Government and, in particular, the Department for Work and Pensions to adopt a more localist approach and to devolve more powers to councils, as we said in a report back in 2011. We note that local authorities already support apprenticeships and back-to-work schemes, but the Government should consider devolving to local government further measures, including elements of the Work Programme, in order to address at a more local level unemployment and, in turn, one reason why people may adopt unhealthy lifestyles.

Local authorities working with the Government

93.  The Government, in its White Paper, Healthy Lives, Healthy People, stated:

Where the case for central action is justified, the Government will aim to use the least intrusive approach necessary to achieve the desired effect. We will in particular seek to use approaches that focus on enabling and guiding people's choices wherever possible.[216]

The Health Select Committee, when it examined public health in 2011, however, found:

While interventions that involved the Government "shoving people" (such as the ban on smoking in enclosed public places) were demonstrably effective, nudging, which was ill-defined ("a very flaky, slippery term"), was little supported by evidence […] The recent report from the House of Lords Science and Technology Committee has since confirmed how thin the evidence base for nudging is, as well as the unevenness of evidence between different fields of behaviour change.[217]

94.  We considered whether the local initiatives referred to in the previous section might, in some cases, require additional and complementary central Government action. Dr Nicholas Hicks, Director of Public Health in Milton Keynes, explained how a target to reduce inequalities in infant mortality had been

supported by concerted action nationally. There were public service agreements and every department bent its actions to that, supplemented by freedom and incentivisation of local authorities through local public service agreements.[218]

Dr Hicks explained that the target had been hit two years early and said that "we do have examples of how, by bending the totality of resources, not just this tiny sliver labelled public health, we can do something that is genuinely wonderful."[219] Other witnesses told us they would be working to engage the Government. Cllr Mary Lea, of Sheffield City Council, said that one of her authority's priorities was

to lobby Government in terms of some of the big health issues that we face: for example, obesity, how food is produced […] manufactured […] advertised and sold. I think there are some changes only the Government can make.[220]

On moving resources to prevention, Cllr Anthony Devenish, of Westminster City Council, was reluctant to call it "lobbying" but said

you have to communicate […] you have to get your message across, and the value for money point […] is that if we can prevent things through reducing binge drinking, that is going to help the NHS overall.[221]

In relation to alcohol-related harm, Newcastle City Council focused on the affordability of drink and was therefore "campaigning as a council for a minimum unit price of alcohol".[222] The Health Minister, Anna Soubry MP, told us of her initial scepticism about a minimum price but revealed how she had subsequently met liver specialists and doctors who "frankly blew me away and completely convinced me that it is a thoroughly good idea."[223] The Government's consultation on the matter finished on 6 February 2013.[224] The Government is currently reviewing the results of the consultation.

95.  Aside from consultation on proposed legislation, the Government has also introduced the "Public Health Responsibility Deal", a voluntary agreement by which businesses commit, for example, to improving the health of their customers and staff, or to helping them to become more physically active.[225] The Department of Health has noted that many local authorities already run local Public Health Responsibility Deals to encourage such activity, and, working with the Local Government Association, local authorities, local businesses and other organisations, the Department is developing "a toolkit to support engagement of local businesses to take simple actions in the areas of alcohol, food, health at work and physical activity."[226] On the next steps nationally in the Responsibility Deal process, Ms Soubry explained that a "bit of naming and shaming is going to happen, because we make it clear that, unless we begin to see substantial changes, we will consider legislation".[227]

96.  In Sweden, the NBHW told us that, on tobacco control, it had recognised the need for input on three levels: state level, which had set prices and an age limit on purchasing; regional level, which as the provider of primary and secondary care had introduced guidelines to ensure patients were ready for surgery; and municipal level, which had responsibility for enforcing the state's rules on price and age.

97.  Some public health issues, such as alcohol misuse and obesity, may require central Government leadership and action, including legislation, if a big difference is to be made to the health of local people. Central Government action will not be a panacea, but to effect change local authorities may require the support of complementary national-level initiatives to make the most of their own strategies, powers and influence. In the meantime, councils do have options available to them, including, setting up or expanding local Public Health Responsibility Deals, with local businesses, on which Government guidelines were published in January 2013. What is clear is that there is no single solution; multiple solutions will be required to deal with the multiple causes of unhealthy behaviour.


98.  In chapter 2, we cited Dr Mike Grady's point that to address the social determinants of health, HWBs would "need the right players in the right room to address the right issue".[228] We noted press reports on 8 November 2012 that the Cabinet sub-committee on public health, which had been established to enable work "across multiple departments to address the wider determinants of health",[229] was being disbanded. Explaining the decision, the Cabinet Office was reported as saying:

Public health issues will now be brought into the broader domestic policy committees rather than sitting with a separate subcommittee. This will allow public health issues to be discussed and decisions to be taken by a wider group of ministers from across government. [230]

When we asked the Government how and when public health issues had been discussed and decisions taken by that "wider group of ministers from across government", the Health Minister, Anna Soubry MP, replied, "I do not know of any,"[231] and Tim Baxter, from the Department of Health, said that "we have plans for engaging with the Home Affairs [Cabinet] Committee; The brutally frank answer is that we have not done so yet."[232] Ms Soubry did add later in the session that she "went to see Edward Timpson in the Department for Education to talk about […] the lack of physical activity in too many of our youngsters".[233]

99.  Since the disbandment of the Cabinet sub-committee on public health, public health issues fall to be discussed and decisions taken in domestic policy committees. We note also plans within the Department of Health to engage with the Home Affairs policy committee, and the discussions that the Department has already had with the Department for Education, which should be encouraged elsewhere in government. Policy alignment nationally will assist councils' efforts to improve health and wellbeing locally and avoid the potential for mixed messages. Given the way in which local health issues span at least two Departments, Health and Communities and Local Government, local authorities need confidence in their contact with Government. In the spirit of close working throughout government, both centrally and locally, we recommend that the Department of Health and the Department for Communities and Local Government set up a single point of ministerial contact to which local authorities can turn for support in their new health care role.

Measuring success

100.  The Government, as part of its health reforms, has developed three frameworks from which bodies with responsibility for health can identify the outcomes they would like to achieve as a result of their work: the NHS Outcomes Framework, the Public Health Outcomes Framework and the Adult Social Care Outcomes Framework. The Government explained that:

The purpose of developing three separate frameworks has always been to ensure focussed rather than blurred accountability and to recognise the different delivery systems and accountability models for the NHS, for public health and for adult social care […]

the NHS Future Forum presented a model in which it should, in certain areas, be possible to set specific outcomes for the different sectors that contribute to broader outcomes that are shared between the different sectors. The Government supports this model […]. However, the pace at which greater alignment of this type can be achieved will necessarily be constrained by current data and indicator availability.[234]

Dr Penny Toff, of the BMA, told us that the public health outcomes framework "as a way of monitoring what is going on locally" was "very sound", although to encourage integrated working and to put aside "individual agendas" she considered "it would probably be helpful to have a more overarching national framework around integrated care."[235] Tim Baxter, from the Department of Health, cited the public health outcomes framework as a systematic way of measuring success, highlighting its 66 "wide-ranging" indicators on "things like reoffending rates, school readiness, smoking prevalence, vaccination rates and premature mortality."[236] We noted earlier in this chapter how improvements in school readiness rates could be a useful short-term measurement of success.[237] In that context, we also heard that the figure for NEETs (those not in education, employment or training) would demonstrate "within a short period" whether an impact was being made.[238] The Royal Town Planning Institute was, however, keen to expand that indicator to include in the outcomes framework an overall assessment of worklessness rather than just of NEETS, and to include overcrowding and housing.[239]

101.  Westminster City Council, while it found the absence of clear objectives from the Government "provided space for local authorities to determine local objectives which fit local needs," noted:

Where the lack of national clarity may be problematic is balancing the local approaches to public health with the Department of Health's approach to measuring the impact of the new arrangements.[240]

Professor Gabriel Scally, of the University of the West of England, told us that authorities would need to be able to measure their data alongside a range of comparators, nationally and internationally. For example, although in the south-west some areas were better than the English average, this did not provide a complete picture as "the overall position of England is so much worse than other countries."[241] He concluded that "people must be allowed to act within the system in the interest of the population they serve", whether the population of England or of a local authority.[242]

102.  We also heard about the risks involved in assessing what works. Newcastle City Council, while acknowledging the importance of measuring health and wellbeing, and any changes in inequalities in health and wellbeing, stated that

there is a risk such measurement becomes an end in itself […]. Measuring impact in the short-term can lead us to focus on individual interventions where there is a greater evidence base, rather than enable us to use our energy and resources to drive social change that will lead to sustained improvements for wellbeing and health for this and future generations.[243]

Dr Toff made a similar point, telling us about the lack of data on marginalised communities and when measuring, for example, childhood obesity levels, not to ignore "what is happening to groups that would not necessarily be included within those measurements."[244] Liam Hughes, the independent chair of Oldham's shadow HWB, said that a key indicator of success "should be the scale of the redirection of commissioning investment upstream into prevention."[245] He accepted that "further upstream" into prevention, it would be difficult to draw a direct link between cause and effect, as any analyst would then be dealing with "the conditions of life rather than some preventive intervention", but he cited work in Oldham on premature mortality, to which we referred in chapter 3, using the current figure for men dying and the direct interventions that might reduce it, as an example of good evidence and a targeted, measurable programme that the HWB was going to implement.[246]

103.  Mr Hughes also drew our attention to the impact of external factors:

Many boards are concerned about the impact of major policy changes on health, especially the welfare reforms […] for some of the most vulnerable people in our society, the combination of reduced income, more insecure housing and reduced support will work against the grain of health improvement.[247]

Sheffield City Council pointed out that measuring the impact of public health programmes on populations continued to be a challenge:

This is because public health initiatives take place in the context of continuing change within society, which in turn impacts on health […]. Thus, for example, the current economic recession is likely to have far more extensive impact (negatively) on the health of the population than locally managed, relatively poorly resourced, public health programmes.[248]

It also explained that it would use its resources "to focus on interventions which are proven to make the biggest impact on well-being".[249] Some examples that drive home its point are shown below. Professor Chris Bentley provided one example of a methodological intervention that could be easily measured. He noted in Birmingham the correlation between the incidence of people with heart disease and their non-registration with a GP and, extrapolating that evidence to people with other long-term conditions, explained that it was clear only half the people with such conditions knew they had them. He therefore suggested that all HWB partners could contribute to the solution by educating the public about the issue, by searching for the "'missing thousands" of non-registered patients and by helping them to connect with the services available, explaining that as a result, "GPs will then be able to improve their own performance in relation to registering patients, and getting them on the best treatment".[250]

104.  The transfer of functions from central to local government during the relocation of responsibilities for public health must not become an end in itself. Local authorities will need to provide within an agreed period evidence of an improvement in the health and wellbeing of their population. With these new powers comes the responsibility to deliver results, and local authorities will need to balance local and national objectives and short-term and long-term aims. Given the complex, multi-faceted nature of the social determinants of health, however, determining the success of general—population-wide—or specific initiatives will be difficult, time-consuming and may ultimately distract those working on them from making progress. Short-term success can be demonstrated relatively quickly, and without distracting from longer-term objectives, by, for example, improvement in readiness for school rates, the number of NEETs (those not in education, employment or training) in a local area and by all Health and Wellbeing Board members working to increase patient registration with GPs in order to identify those with long-term conditions and to prescribe treatment for them.


105.  The relationship between the national and the local in measuring success was also reflected comments on who should conduct the assessment. Cllr Alan Connett, from the District Councils' Network, referred to Healthwatch, scrutiny committees and ultimately the electorate as the bodies that should hold local authorities to account.[251] Cllr Steve Bedser, from the LGA and Birmingham City Council, said he was "reluctant to be held to account from day one, because in some local authorities we inherit very stark inequalities", but he also said "health scrutiny and Healthwatch are going to be very important in keeping some local temperature".[252] Dr Peter Carter, of the Royal College of Nursing (RCN), cited hospitals at the bottom of league tables which "feel quite persecuted by it, when it is often a reflection of the population they are serving […] In the first few years […] we need to be careful not to set unrealistic targets for local authorities, because this is about behavioural and lifestyle change."[253] Liam Hughes, from Oldham's shadow HWB, said that PHE was "conscious that the switch from top-down direction to sector-led improvement requires first-rate data and intelligence, the identification of blind-spots, and the will to take action about them." He added that PHE should therefore "be more of an ally and 'critical friend' than a regulator".[254]

106.  Good local authorities may already be tackling the difficult challenges posed by unhealthy people and communities, so in the short term at least it would be unfair and possibly counter-productive to start "naming and shaming" councils without taking into account historical and demographical factors. With Public Health England in its infancy it makes sense to restrict its role to that of critical friend. On matters of scrutiny and regulation, local authorities should not hide behind a national body such as Public Health England. We encourage them, in the spirit of localism, to take responsibility for these issues themselves, through overview and scrutiny committees and Local Healthwatch.


107.  Witnesses drew our attention to one aspect of measurement, self-assessment, as an effective means of both obtaining information about people and involving them in their own care. Caroline Abrahams, of Age UK, told us that, because older people when asked had included social contact in their definition of wellbeing, it was important to measure their levels of participation in society, adding, "you could do that through surveys […] working with and through voluntary sector organisations."[255] Paul Woodward, of Sue Ryder, agreed, telling us that its younger service users also had broad ambitions, to maintain their independence, spend time with their family and engage with the community, adding that "you could certainly look at that through surveys" and that he saw no way of measuring it "other than asking people whether they are actually getting it or not."[256] This idea of making the most of the knowledge of service users as well as providers was, Dr Mike Grady told us, an element in the co-production of health and wellbeing which "encourages people and communities to participate in public services on an equal basis with professionals".[257]

108.  Surveys—self-assessments—are a useful measure of wellbeing: they quantify the less specific but no less important objectives of independence and social participation, and they engage individuals in the development of their own wellbeing. Councils might make such surveys one aspect of agreeing their contracts with voluntary groups.

184   Ev w6, para 10 Back

185   Ev w6, paras 5, 11 Back

186   Q 3 Back

187   Q 238 Back

188   Q 235 Back

189   Ev 127, para 1 Back

190   Q 3 Back

191   Ev 160 Back

192   Q 232; the King's Fund also explained that separate strategies to tackle different examples of unhealthy behaviour had not worked, because "unhealthy behaviours co-occur and cluster in population groups, particularly in the most disadvantaged populations," and concluded: "Local authorities, with their greater knowledge of local communities-and their greater control over some of the economic and social conditions that shape behaviours-should be in a better position to do this than the NHS", Ev 78. Back

193   Q 170 Back

194   As above Back

195   Planning Use Class Orders, Standard Note, SN/SC/1301, House of Commons Library, January 2013 Back

196   Planning Use Class Orders, Standard Note, SN/SC/1301, House of Commons Library, January 2013 Back

197   Local Government Information Unit and Westminster City Council, A dose of localism: the role of councils in public health, p 6 Back

198   "Obese who refuse to exercise 'could face benefits cut'," BBC News Online, 3 January 2013 Back

199   Local Government Information Unit and Westminster City Council, A dose of localism: the role of councils in public health, p 5 Back

200   Q 290 Back

201   Ev 164 Back

202   Q 305 Back

203   The Marmot Review, Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post 2010, p 39 Back

204   The Marmot Review, Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post 2010, p 60 Back

205   Q 287 Back

206   As above Back

207   Q 170 Back

208   Q 232 Back

209   Q 170 Back

210   Ev 120, paras 22, 23 Back

211   Ben Barr, David Taylor-Robinson and Margaret Whitehead, "Impact on health inequalities of rising prosperity in England 1998-2007, and implications for performance incentives: longitudinal ecological study", British Medical Journal, 2012, ref: 335:e7831, p 1 Back

212   Q 214 [Newcastle]; see also Ev 120, para 22 [Westminster] and Q186 [Sheffield]. Back

213   Q 199 Back

214   Communities and Local Government Committee, Third Report of Session 2010-11, Localism, HC 547, para 32 Back

215   Q 381 Back

216   HM Government, Healthy Lives, Healthy People: Our Strategy for Public Health in England, CM 7985, para 2.33 Back

217   Health Committee, Twelfth Report of Session 2010-12, Public Health, HC 1048-I, para 277 Back

218   Q 36 Back

219   Q 36 Back

220   Q 170 Back

221   Q 221 Back

222   Q 170 Back

223   Q 321 Back

224   A minimum price for alcohol?, Standard Note, House of Commons Library, SN/HA/5021, 12 February 2013 Back

225   Department of Health, "Public Health Responsibility Deal: Core Commitments", Back

226   Department of Health, "A toolkit for supporting engagement with local business", Back

227   Q 324 Back

228   Q 228 Back

229   HM Government, Healthy Lives, Healthy People: Our Strategy for Public Health in England, CM 7985, November 2010, executive summary, para 4 Back

230   "Doctors dismayed as public health committee is scrapped", The Guardian Online, 8 November 2012, Back

231   Q 326 Back

232   Q 327 Back

233   As above Back

234   Department of Health, The NHS Outcomes Framework, 2012/13, Back

235   Q 63 Back

236   Q 386 Back

237   See "Early years" section in this chapter, and Q 227 [Dr Mike Grady]. Back

238   Q 227 [Dr Mike Grady] Back

239   Q 135 [Richard Blyth] Back

240   Ev 120, paras 14-15 Back

241   Q 64 Back

242   Q 65 Back

243   Ev 123 Back

244   Q 69 Back

245   Ev 125 Back

246   Q 217 Back

247   Ev 126 Back

248   Ev 131, para 36 Back

249   Ev 127, para 6 Back

250   Ev 154 Back

251   Q 72 Back

252   Qq 72, 74 Back

253   Q 75 Back

254   Ev 125 Back

255   Q 143 Back

256   Q 146 Back

257   Ev 148 Back

previous page contents next page

© Parliamentary copyright 2013
Prepared 27 March 2013