6 Finance
Introduction
129. In February 2012, the Government produced
a draft interim public health funding allocation for local authorities.
This was updated in June 2012. In January 2013, the Government
announced its final public health funding allocation.
130. In Healthy Lives, Healthy People, the
Government set out its approach to financing the public health
work carried out by local authorities:
It is time to prioritise public health. The Government
will ring-fence public health funds from within the overall NHS
budget to ensure that it is prioritised [
]. Alongside the
shift of power from Whitehall to local communities we will allocate
ring-fenced funds for public health to local authorities to enable
them to secure better health and reduce inequalities, working
with the NHS and other key partners in their areas.[306]
The Departments of Health and for Communities and
Local Government, in their joint submission to our inquiry, provided
further details of the proposed funding system:
From 2013-14 upper tier and unitary local authorities
will be allocated ring-fenced public health grants to improve
the health and wellbeing of local populations [
]. The Advisory
Committee on Resource Allocation (ACRA), an independent expert
committee that has overseen the formula used to allocate NHS resources
for many years, is developing a formula for the allocation of
resources to local authorities for public health.[307]
In preparation for 2013-14, the Departments also
explained the draft interim public health funding allocation and
the status of the funding process:
Baseline spending estimates for each local authority
published in February 2012 estimated that in 2012-13 around £5.2
billion will be spent on the future responsibilities of the public
health system, including £2.2 billion on services that will
be the responsibility of local authorities [
] ACRA's interim
recommendations (for 2013-14) were published on 14 June 2012.[308]
131. In this chapter we consider: first, the
formula used in 2012 for funding local public health functions
and its implications for local government budget preparations;
second, the new formula produced in January 2013 and the Government's
arrangements for redeveloping it; and, third, how those arrangements
relate to the Health Premium, the Government's preferred method
for incentivising authorities to tackle health inequalities.
THE DRAFT INTERIM ALLOCATION
132. The ACRA, in its draft interim allocation,
opted for a funding model based on the under-75 standardised mortality
ratio (SMR), an approach that uses the population size of each
local authority and the number of people dying before 75 years
old as the indicator of relative need[309]
to allocate the available budget. When the draft interim public
health budget was published in February 2012, the Department of
Health explained that "understanding baseline spend is just
the first step in establishing future budgets, and further analysis
will build on this,"[310]
and in June 2012 it described how "an active period of engagement
and consultation will take place following publication of ACRA's
interim recommendations".[311]
133. The interim allocation prompted considerable
criticism in the evidence we received. First, on the methodology,
Core Cities, an organisation of England's eight largest cities
outside London, suggested that the use of standard mortality rates
would "result in redistributing funds away from some of the
most deprived areas in the country." The NHS Confederation
told us "the proposed funding formula would leave local authorities
in the most deprived 30% of areas worse off, losing an average
of £8 per resident, and those in the most affluent 20% of
areas gaining by the same amount".[312]
Second, on the time taken to consult on the interim formula and
devise a final funding settlement, Duncan Selbie, Chief Executive-designate
of Public Health England (PHE), explained that, if
you asked [the Department of Health] what they had
been spending on public health, they did not know because we did
not ask. The first thing we had to do was establish the base line
[
] It is not a satisfactory starting position, because we
are not addressing what you should be spending, which is the formula,
but what you are spending.[313]
Mr Selbie also cited two additional reasons for the
length of the allocation process:
It was the first time we had ever gone through this
exercise. We have to make sure that we are covering what is currently
being spentthat is what the focus has been onconcurrently
with the examination of a formula.[314]
134. Understandably, local authorities had to
plan on the basis of the figures announced in 2012. (The final
allocations were not published until January 2013.) Local authorities,
their contractors and service providers were therefore compelled
to develop commissioning plans and to set budgets for 2013-14
based on unknown but potentially significant changes in funding.
Cllr Steve Bedser, from the Local Government Association, told
us in oral evidence "it is now the end of November [2012],
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".[315]
Cllr Roger Gough, Cabinet Member for Business Strategy, Performance
and Health Reform at Kent County Council, explained in early December
2012 that there was "uncertainty about public health budgets
and there is uncertainty about total budgets [
] that should
be clarified sometime between now and Christmas, but it is extremely
late in the day".[316]
Kim Carey, Corporate Director, Adult Care and Support, at Cornwall
Council, said: "We are flagging the budget transfer high
on our risk programme, and it is becoming more of a risk the closer
we get to the transfer of the service".[317]
Cllr Ernie White, Cabinet Lead Member for Health on Leicestershire
County Council, said that it was a problem not just for the public
health budget, but for all the authority's partner organisations
attempting to plan commissioning based on the Joint Strategic
Needs Assessment: "They were all saying, 'We do not know
our budget [
] we really cannot get into a positive mood
about sharing'".[318]
THE FINAL ALLOCATION
135. On 10 January 2013 the Department of Health
published local authorities' individual public health budgets,
explaining that it had decided to finalise allocations not just
for 2013-14 but for 2014-15. The Department said that "providing
a two-year budget will [
] give local authorities a clearer
long-term understanding of their future funding as they prepare
to take on their new responsibilities". It announced that
the overall budget would rise to £2.66 billion in 2013-14in
contrast with the draft interim allocation for that financial
year of £2.2 billionand to almost £2.8 billion
in 2014-15.[319] With
the allocation, no local authority would receive less than a 2.8%
increase in their funding when compared with the baseline year
of 2010-11, and the maximum increase would be 10%.
136. When the final funding allocation was announced,
Cllr David Rogers, Chairman of the Local Government Association's
Community Wellbeing Board, welcomed it but said that
the biggest concern among councils was around the
delay on the final funding decision. Today's announcement will
give councils confidence that they have the money they need, but
leaves a tight timescale of just three months to put plans in
place to deliver on their statutory responsibilities for public
health.[320]
137. We welcome the increasewhen
compared with the draft interim allocationin public health
funding to local authorities. We recognise that to create a public
health budget where none has previously existed, to finalise a
formula and to consult with all those affected is not a task to
be taken lightly or rushed, but the 11 months required to complete
the final allocations process, with totals being announced on
10 January 2013, only 79 days before health responsibilities transferred
from the NHS, left local authorities with a great deal of work
to do in a short period. Local government understandably planned
for the worst based on the interim February 2012 and June 2012
allocations, and, while the subsequent increases are welcome,
the delay caused some problems for local authorities and their
budgeting arrangements.
138. Given that local authority
public health budgets have now been set for 2013-14 and 2014-15,
the Government has time to plan with local government a managed
approach to allocating the budgets for 2015-16. We therefore recommend
that the Government puts in place a timetable for publishing and
consulting on the 2015-16 allocations with a view to finalising
them by October 2014, so that commissioners and providers have
at least six months in which to plan strategically the services
that will contribute most effectively to local people's health
and wellbeing in 2015-16.
The revised formula
139. The revised formula was based on updated
estimates of historical spending and on changes to the weighting
applied in the interim allocation. ACRA based its final allocation
on updated PCT estimates of their public health spending in 2010-11,[321]
and the Department of Health explained that, although it would
continue to use the standardised mortality ratio for those aged
under 75 years as the basis for allocating funds, it would apply
the ratio to smaller, more localised populations of between 5,000
and 15,000 people "to take account of inequality within local
authorities as well as between local authorities", weight
the formula to "target funding towards areas with the poorest
health outcomes", and apply an age-gender adjustment "to
those services with the highest proportion of public health spend
which are also directed at specific age-gender groups".[322]
Tim Baxter, Deputy Director and Head of the Public Health Policy
and Strategy Unit at the Department of Health, explained that
with the SMR "you get the data down effectively to ward-level
[
] You can then get very granular about identifying the
most deprived parts of the population and directing more resource
to them".[323]
The Royal College of Nursing (RCN) agreed with Cllr Steve Bedser,
of the Local Government Association, about matching resources
to need. Dr Carter saw a responsibility on local authorities to
target the funding it was allocated: "One of the very good
things is that we have rich data. What you [the local authority]
need is a sophisticated local needs assessment, and then you target
the resources where you think the greatest need is".[324]
140. ACRA, in a letter to the Secretary of State
in October 2012 detailing its preferred funding formula, acknowledged
that in the medium term "a health outcome should not be the
main driver of the formula," and explained that:
This is because a local authority which improves
its health outcomes would be at risk of losing future public health
funding and we believe this is a perverse incentive. ACRA will
continue to work on a formula based more on the underlying drivers
of need.[325]
ACRA also expressed "a desire to develop a more
evidence based formula".[326]
When we asked Mr Baxter whether health outcomes should be the
main driver of funding, given that a local authority which improved
them would risk losing future funding, he accepted there was such
a perverse incentive and said the formula would be reviewed.[327]
In supplementary written evidence the Government said, however,
that: "no specific timetable has been set for the next iteration
of the public health allocations formula".[328]
141. We acknowledge that the
current formula is an improvement on the interim model and allows
local authorities to target pockets of deprivation in their areas.
We note the perverse incentive in the medium term, however, of
basing funding on improved health outcomes, given that areas which
perform well risk having their funding reduced. Public health
is not short of data, and it should be possible under the new
arrangements to begin to base funding on observable trends in
health locally andusing Joint Strategic Needs Assessments,
for examplefor local government to use its allocations
in a more precise manner. This places a responsibility on councils
and their Health and Wellbeing Boards to produce comprehensive
and rigorous Joint Strategic Needs Assessments.
142. We recommend that the
Government not only ensures the Advisory Committee on Resource
Allocation makes good on its commitment to review the allocation
formula, but clarifies the timetable for revising itand
whether this means a revised formula in time for the 2015-16 allocations.
Just as local authorities need to know well in advance when budgets
will be published, they require also some certainty about the
formula that will be used to calculate them.
THE HEALTH PREMIUM
143. The Health Premium is a cash incentive payable
to those local authorities that make progress against public health
indicators, including fewer children under 5 with tooth decay,
more women breastfeeding their babies and fewer over 65s suffering
from falls.[329] The
premium would, in the Government's view, "reward improvements
in health outcomes, and incentivise action to reduce health inequalities".[330]
It was scheduled for introduction in 2015,[331]
and the need to clarify the formula to be used in allocations
from 2015-16 was therefore given greater urgency by the Government's
acknowledgement, in its supplementary written evidence, that any
perverse incentive in the current formula would be
particularly marked were the current formula still
in use alongside the Health Premium Incentive Scheme. We expect
the first payments to be made under this scheme in 2015/16 and
so this will also be a key year in the development of the formula.[332]
144. The Health Premium itself, as a stand-alone
funding mechanism, was criticised during our inquiry. The RCN
considered that the premium would be of little assistance to disadvantaged
areas "that fail to make any progress as a result of the
comparative greater disadvantage of their populace," a problem
that would be remedied only by weighting the public health allocation
"to reflect the deprivation that an area experiences".[333]
Sheffield City Council said that the premium would "inappropriately
and unfairly reward those areas where health is improving anyway,
where arguably less public health resource is needed",[334]
and Professor Scally considered that the timescales involved in
public health were too long to make the health premium "attractive".[335]
145. The Government's approach
to public health funding leading up to and after 2015-16 seems
confused and should be clarified. It says it has no timetable
for modifying the current funding formula, but accepts that, given
the impact of the Health Premium, the formula will need to be
developed in 2015-16. Local authorities will need to know, first,
when they can start planning their budgets for 2015-16, second,
when the Government intends to redevelop the funding formula,
and, third, that any system of reward will complement their main
source of funding.
146. The Government has acknowledged
that the perverse incentive in the current funding formula would
be particularly marked if it were still in place when the Health
Premium was introduced. This suggests that the current funding
formula and possibly the Premium need to be revised. A funding
system which at the same time disadvantages and rewards improvements
in public health cannot be fit for purpose. The Government has
said that 2015-16 will be a key year in the development of the
formula. We recommend that a parallel system of reward should
not be implemented in the same year. It should be delayed until
the funding formula has been redesigned.
DEMAND-LED SERVICES
147. A number of witnesses drew our attention
to demand-led services and, in particular, to the issue of mandated
sexual health services. Dr John Middleton, Director of Public
Health at Sandwell PCT and Vice-President of the Faculty of Public
Health, said that, while basis of the formula could well be deprivation
or mortality,
The problem is that, when you look at what is in
the ring-fenced budget, it is not about premature mortality; it
is about genitourinary medicine services, school nursing and drugs
and alcohol services. We have used one formula potentially to
describe a totally different set of problems and answers [
]
In Westminster two-thirds of the budget goes on the GU medicine
service, and they could spend all of the ring-fence in a very
short space of time with those increases in activity.[336]
148. Cllr Anthony Devenish of Westminster City
Council described an alternative method of charging for such services
which the Council, along with other London local authorities,
had submitted to the Department of Health.[337]
This method used, instead of the under-75 standard mortality ratio,
the index of multiple deprivation, which was "associated
with high levels of public health needs such as drug and alcohol
use, population churn and mandated sexual health services".[338]
Using demand-based allocations as a proxy for need, it was calculated
that Westminster would receive an extra £4 million.[339]
In the final allocation for 2013-14, it actually received only
an extra £827,000.[340]
149. Those concerns were recognised in part.
ACRA, in a letter to the Secretary of State, explained that concerns
the SMR might not be suitably linked to the need for sexual health
services were "valid",[341]
and Tim Baxter from the Department of Health acknowledged: "Sexual
health services is an area that ACRA is going to have to continue
to look at".[342]
150. The costs of demand-led
services, such as sexual health provision, are increasing and
in some cases could account for a considerable proportion of the
public health ring-fenced grant from April 2013. It has
been argued that the current formula fails to account adequately
for the cost of these services, and we have received evidence
detailing alternative funding criteria that might correspond more
accurately to the care that local authorities have been mandated
to provide. The Advisory Committee on Resource Allocation,
while acknowledging these concerns, maintained that no immediate
alternative appeared to work across the country. We recommend
that the Government and the advisory committee, as part of their
commitment to keep this area under review, consider alternative
formulas for calculating the overall ring-fenced grant, such as
the index of multiple deprivation, and how such allocations might
take better account of local circumstances.
RE-CHARGING FOR NON-RESIDENTS' USE
OF SERVICES
151. Westminster City Council also told us about
a need to allocate resources not only for its 200,000 residents,
but for the 750,000 people who came into the city every day. Newcastle
City Council faced similar pressures. Cllr Nick Forbes, Leader
of the Council, said that "we suffer from a not dissimilar
phenomenon [to Westminster's], which is that the number of people
who turn up and use Newcastle's services is far higher than the
number of Newcastle-based residents".[343]
ACRA did not recommend any adjustment in funding to account for
non-resident populations' use of sexual health services, preferring
to encourage the development of a re-charging approach between
authorities.[344] In
its evidence the Department of Health said that non-residents'
use of services was significant only in the City of London and
explained that local authorities could pool their budgets, as
well as re-charge each other, to pay for these services.[345]
In the face of the evidence from Westminster and Newcastle we
are not persuaded that the Government's approach is adequate.
We call
on ACRA and the Government to work with local authorities on the
issue of non-residents' use of demand-led services. Given that
many people work or go out in one borough and live in another,
people's use of services in this way should not be underestimated.
Attempting to resolve that either by pooling resources or by re-charging
has the potential to become complicated and contentious.
Funding in the long term
MOVING AWAY FROM RING FENCING
152. Funding demand-led services highlighted
the question whether in the long term public health funding should
be ring fenced at all or, for example, relocated within a community
budgets. These are general funds for a whole area and its people,
rather than separate budgets for separate services such as health,
transport and education. The RCN was concerned that
more than half of the Public Health money going to
local authorities, has been identified as necessary spend for
sexual health and substance misuse services, which are demand-led
services. This presents real problems and significantly reduces
the funding available to invest in prevention work on issues like
obesity and smoking. [346]
153. David Buck, Senior Fellow, Public Health
and Inequalities, at the King's Fund, queried the use of a formula
in the first place, saying that
if you have a given a pot of money and you give a
local authority mandatory things to deliver, you should make an
attempt to look at how much it costs to deliver services from
a bottom-up perspective [
] a formula may be good approach
to distributing what is left. [347]
This approach, of assessing the cost of a service
before introducing a budget for it, was referred to by ACRA in
its letter to the Secretary of State, when it said it would consider
"a bottom-up costing, based on a model of what services might
be offered to populations with different needs".[348]
154. We urge local authorities
and the Government to explore innovative approaches to funding
public health services. One route might be to determine the actual
cost locally of demand-led services and to separate funding for
them from the rest of the public health budget. The remaining
public health provision could then be determined using a formula,
such as the standard mortality ratio, and either continue to be
ring fenced or stand apart from the rest of the authority's budget.
Alternatively, the remainder might, as witnesses suggested, correspond
to the remainder of the local authority's overall budget and become
in all but name a community budget.
COMMUNITY BUDGETS
155. During our evidence sessions, clinicians
favoured and council representatives opposed ring-fencing the
public health budget.[349]
All agreed, however, that ring fencing would be important in the
short term to protect investment in the fledgling public health
system. Opponents wanted to remove the ring fence completely in
the medium term so that local authorities might pool their public
health resources, including those for demand-led services, along
the lines of community, place-based budgets.
156. Those who favoured the eventual removal
of the ring fence saw this step as fundamental to the new system
if all local authority departments were to incorporate public
health into their plans and services and to take full advantage
of the relocation of public health to local government. Dr Nicholas
Hicks, Director of Public Health in Milton Keynes, told us that,
when a local authority's entire budget was considered "public
health" spending, the proportion required to fund demand-led
services would diminish accordingly. He was
more interested in the total allocation in the community
rather than the tiny percentage of that that is called the public
health budget [
] sexual health services, substance misuse
services and health checks [
] are all good things to do,
but they are a small subset of public health and not the major
mechanisms to tackle inequalities.[350]
157. Cllr Steve Bedser of the Local Government
Association, warned that "if it (the funding) 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 [
] and bring alive all of the very real
opportunities that exist within the transfer".[351]
Dr Mike Grady, of the UCL Institute of Health Equity, agreed that
in the long term a transition from ring-fenced funding to place-based
funding was logical:
the evidence supports it [
] the total-place
pilots [
] were very good examples of greater efficiencies,
savings, engagement of communities, and co-production of services
with people and communities.[352]
The example of Total Place pilot budgets was cited
also by Cllr Nick Forbes from Newcastle, who pointed to turf wars
between adult social care, children's social care and health service
delivery, and concluded, "what we need is a total-place budget
approach that looks at the whole system from a population and
people perspective rather than an organisational perspective."[353]
The King's Fund also explained that Total Place had shown "promising
improvements for local populations,"[354]
making the case for a joined-up, population-focused approach,
given that separate strategies for obesity, smoking and alcohol
had not connected with each other or to policies on health inequalities.[355]
158. We also heard how existing place-based budgeting
system might be transposed on to public health. Newcastle City
Council had found that multiple funding streams with different
requirements did not help its service delivery, especially when
investment made in one place resulted in savings elsewhere, and
so the council had decided to pursue "the idea of a health
and social care 'city deal'to give us more flexibility
around both investment and re-investment," and said that
it was establishing a social care commission to investigate the
idea.[356] Sheffield
City Council also referred to its "successful City Deal recently
agreed with Government" to promote and create opportunities
for economic growth as an example of the powers it would require
"to address the health and wellbeing problems which exacerbate
benefit dependency, poverty, low incomes and productivity lags
in our economies".[357]
159. The final funding settlements made in January
2013 have, however, allowed for a form of budgetary integration.
The Government explained that ACRA's interim recommendations included
"provision for pooling of the ring-fenced public health budget,
including as part of a Community Budget,"[358]
and the Government said that the grant conditions for the final
settlement "specifically" allowed the money to be pooled
with other budgets and across local authorities.[359]
Tim Baxter from the Department of Health explained that the Department
"very much" wanted to learn from "the community
budgets [
] pilots looking at health and social care".[360]
He added that the "funding mechanisms are obviously very
important but the shared objectives as to how the money is spent
are the most crucial thing".[361]
160. The Parliamentary Under-Secretary of State
for Communities and Local Government, Baroness Hanham, accepted
that "local government does not like ring-fenced grants"
but drew attention to the role a Director of Public Health covering
multiple local authorities might play in overseeing how resources
were pooled,[362] and
other witnesses also emphasised the pivotal position of the Director
of Public Health, reaching across their local authority and out
to the NHS, in order to safeguard public health money and to advise
on its most appropriate use.[363]
Both Departments placed some responsibility for developing a shared
approach to resources on HWBs, explaining that as part of HWBs'
duties to encourage integrated working, "they will consider
how the collective resources of the NHS and local government can
combine to improve outcomes, for example through Community Budgets".[364]
161. We agree with the Department
of Health that, although funding mechanisms are important, shared
objectives on how the money is spent are crucial. While the Department
for Communities and Local Government recognises that local government
does not like ring-fenced grants, we accept that, at least in
the short term, some ring-fencing may be needed. But this should
not become a permanent feature of the public health funding system
in England. The Department of Health says it wants to learn from
the Community Budget pilots on health and social care. We urge
the Department of Health to work with the Department for Communities
and Local Government and to share that learning as soon as possible,
in order to clarify what funding mechanism will be proposed for
the financial year 2015-16 and beyondwith a view to removing
the ring fence and moving to community budgets. In addition, we
urge the Government and, in particular, the Department of Health
to recognise that if public health is to become an overarching
priority for all local authority departments, it will require
an overarching budget which reflects that approach. If the evidence
from the completed Total Place and ongoing Community Budgets pilots
continues to point to their effectiveness, we recommend the Government
provides local authorities with community, place-based, budgets
for the direction of resources at people and places rather than
at organisations.
- There is also a role for Health
and Wellbeing Boards to play, given their duty to encourage integrated
working, by devising joint strategies that allow local authorities
to use existing levers in the final funding settlement to pool
public health budgets with those of other departments and across
authorities, thereby demonstrating to central Government how shared
resources can improve outcomes. In this endeavour, Directors of
Public Health will remain central to the budgeting process if
and when the ring fence is removed.
306 HM Government, Healthy Lives, Healthy People:
Our Strategy for Public Health in England, cm 7985, pp 26,
27 Back
307
Ev 168, paras 39, 40 Back
308
Ev 168, paras 39, 41 Back
309
The ratio was explained in a letter from David Fillingham, Chair
of ACRA, to the Health Secretary, 17 October 2012, pp 1,2. Available
at https://www.wp.dh.gov.uk/publications/ Back
310
"Baseline spending estimates for new NHS and public health
commissioning published", Department of Health press release,
7 February 2012, www.dh.gov.uk/health/2012/02/baseline-allocations/ Back
311
"Update on public health funding for local government",
Department of Health press release, 14 June 2012, www.dh.gov.uk/health/2012/06/ph-funding-la/ Back
312
Ev w 42, para 7.3 Back
313
Q 32 Back
314
As above Back
315
Q 88 Back
316
Q 238 Back
317
Q 240 Back
318
Q 237 Back
319
"Ring fenced public health grants to local authorities 2013-14
and 2014-15 published", Department of Health press release,
10 January 2013, www.dh.gov.uk/health/ Back
320
"Councils respond to extra funding for public health",
Local Government Association press release, 10 January 2013, www.local.gov.uk Back
321
Department of Health, Exposition Book Public Health Allocations
2013-14 and 2014-15: Technical Guide, p 11 https://www.wp.dh.gov.uk/publications/files/2013/01/Public-Health-Weighted-Capitation-FormulaTechnical-Guide-v0.13.pdf Back
322
Department of Health, Exposition Book Public Health Allocations
2013-14 and 2014-15: Technical Guide, p 7 https://www.wp.dh.gov.uk/publications/files/2013/01/Public-Health-Weighted-Capitation-FormulaTechnical-Guide-v0.13.pdf Back
323
Q 353 Back
324
Q 97 Back
325
Letter from David Fillingham, Chair of ACRA, to the Health Secretary,
17 October 2012, p 5 https://www.wp.dh.gov.uk/publications/files/2013/01/DF-letter-to-SoS.pdf Back
326
Letter from David Fillingham, Chair of ACRA, to the Health Secretary,
17 October 2012, p 5 https://www.wp.dh.gov.uk/publications/files/2013/01/DF-letter-to-SoS.pdf Back
327
Qq 355-56 Back
328
Ev 171 Back
329
"Helping people live healthier lives", Department of
Health press release, 23 January 2012, www.dh.gov.uk/health/2012/01/future-for-public-health/ Back
330
Ev 168, para 41 Back
331
"Health improvement funds delayed until 2015",
The Local Government Chronicle Online, 14 June 2012 www.lgcplus.com/topics/health/health-improvement-funds-delayed-until-2015/5045970.article Back
332
Ev 171 Back
333
Ev 106, para 5.8 Back
334
Ev 131, para 37 Back
335
Q 100 Back
336
Q 38 Back
337
Qq 188, 189 Back
338
HLTH B03, Letter from Central London Forward and London Borough
of Hammersmith and Fulham local authorities to the Secretary of
State for Health, 29 November 2012, [not published], appendix
A, para 1 Back
339
HLTH B03, Letter from Central London Forward and London Borough
of Hammersmith and Fulham local authorities to the Secretary of
State for Health 29 November 2012, [not published], appendix A,
para 2 Back
340
See Department of Health, "Public Health Grants to Local
Authorities 2013-14 and 2014-15", https://www.wp.dh.gov.uk/publications/files/2013/01/Public-Health-Grants-to-Local-Authorities.pdf. Back
341
Letter from David Fillingham, Chair of ACRA, to the Health Secretary,
17 October 2012, p 3 https://www.wp.dh.gov.uk/publications/files/2013/01/DF-letter-to-SoS.pdf Back
342
Q 359 Back
343
Q 190 Back
344
Letter from David Fillingham, Chair of ACRA, to the Health Secretary,
17 October 2012, p 4 https://www.wp.dh.gov.uk/publications/files/2013/01/DF-letter-to-SoS.pdf Back
345
Q 358 [Anna Soubry] Back
346
Ev 106-107, para 7.3 Back
347
Q 29 Back
348
Letter from David Fillingham, Chair of ACRA, to the Health Secretary,
17 October 2012, p 5 https://www.wp.dh.gov.uk/publications/files/2013/01/DF-letter-to-SoS.pdf Back
349
The clinicians in favour were Professor Scally [Q 81], and Dr
Carter [Q 84]; those against were Cllr Alan Connett [Q 82], and
Cllr Steve Bedser [Q88]. Back
350
Q 31 Back
351
Q 90; Cllr Bedser also said the drawback of a ring-fenced approach
was "it defines the limit of public health spend", Q
89. Back
352
Q 243 Back
353
Q 197 Back
354
Ev 77, para 19 Back
355
Ev 78, para 30 Back
356
Ev 123 Back
357
Ev 135, para 59 Back
358
Ev 168, para 40 Back
359
Q 348 Back
360
Q 348 Back
361
Q 352 Back
362
Qq 349, 350 Back
363
See, for example, Q 76 [Dr Penny Toff] and Q 87 [Dr Peter Carter]. Back
364
Ev 167, para 26 Back
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