UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 694-v

House of COMMONS

Oral EVIDENCE

TAKEN BEFORE the

Communities and Local Government Committee

THE ROLE OF LOCAL AUTHORITIES IN HEALTH ISSUES

MONDAY 21 JANUARY 2013

ANNA SOUBRY MP, TIM BAXTER and BARONESS HANHAM CBE

Evidence heard in Public Questions 295-386

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Oral Evidence

Taken before the Communities and Local Government Committee

on Monday 21 January 2013

Members present:

Mr Clive Betts (Chair)

Bob Blackman

Simon Danczuk

Bill Esterson

James Morris

Mark Pawsey

Andy Sawford

John Stevenson

Heather Wheeler

________________

Examination of Witnesses

Witnesses: Anna Soubry MP, Parliamentary Under-Secretary of State, Department of Health, Tim Baxter, Deputy Director, Public Health Development Unit, Department of Health, and Baroness Hanham CBE, Parliamentary Under-Secretary of State, Department for Communities and Local Government, gave evidence.

Q295Chair: Welcome, everyone, to the final evidence session of our inquiry into the role of local authorities in health issues. You are all most welcome this afternoon. Could you say who you are, please? That would be helpful to put into the record.

Tim Baxter: I am Tim Baxter, deputy director and head of the public health policy and strategy unit, Department of Health.

Anna Soubry: I am Anna Soubry, Member of Parliament for Broxtowe and also the Minister for Public Health.

Baroness Hanham: I am Joan Hanham, Parliamentary Under-Secretary of State in the Department for Communities and Local Government.

Q296Chair: You are all most welcome this afternoon. Joan, you have been with us on a number of occasions; for Anna I think it is the first time. Thank you very much, all of you, for coming along. We have taken evidence already, and no doubt you will have seen some of the evidence sessions that we have had. The Committee at one of the sessions was slightly disturbed by what was said to us by the chief executive designate of Public Health England with regard to screening and immunisation services: "There is an issue about screening and immunisation. I agree that we would not have invented this." I would have thought it is not the best start to a new system for the chief executive to question whether the whole structure with regard to screening and immunisation is fit for purpose. Have you got similar concerns, Ministers?

Anna Soubry: Not particularly. The movement of public health back into local authorities, which has been largely uncontroversial, should genuinely be welcomed by everybody. The feedback I am getting is that by and large, with a few exceptions, local authorities are excited at the prospect, and, as I say, it is to be welcomed. I welcome the idea that for immunisation in particular it should be the responsibility of the commissioning board to put it out at the level they intend to. I do not share Duncan’s concerns about it particularly. As you would expect me to say, I am more than willing to listen to anybody, and when it is him who is saying it I particularly hear what he says. I do not know what Tim says about it.

Tim Baxter: I know exactly what Duncan is saying. We did not redesign the whole health system with screening and immunisation in mind. The benefit of the new system is that you will have a single national commissioner for screening and immunisation programmes. There will be an NHS commissioning board. They will be commissioning with evidencebased specifications. There will also be Public Health England staff seconded to the commissioning board, running the screening and immunisation programmes, so you will have a greater critical mass of public health expertise in charge of these programmes. It will be an improvement on the current arrangements.

Q297Chair: What about at local level?

Tim Baxter: At local level it will be run through the 27 area teams of the commissioning board, so it will be sufficiently local to be locally sensitive, but I should also say that, subject to Parliament, local authorities will have a duty to advise on health protection arrangements. They will be able to scrutinise what is happening on screening and immunisation and, if necessary, raise any concerns, and that includes through the health and wellbeing boards.

Q298Chair: You have already mentioned four organisations: the local authorities; the health and wellbeing boards; the commissioning board; and Public Health England. Once you get four organisations involved in doing something, isn’t there a worry that they all try to do it, or they do different things, or nobody does it because they think somebody else is going to do it?

Tim Baxter: The important point to make is about accountability. There will be an agreement between the Department of Health-the Secretary of State-and the commissioning board to commission these programmes, so it will be for the commissioning board to make sure they get things right. I know that this is being treated very seriously. There are senior people in the commissioning board and Public Health England who are very much focused on ensuring that we have the people in place to transfer the responsibility for these programmes from next April.

Anna Soubry: One of the really good things about this system is that health and wellbeing boards, which are part and parcel of the local authority, are exactly the places where local people, whether they are elected representatives or their CCGs-in other words, local GPs-may well say they have a problem. To take TB as an example, they may say, "In our particular area we have a big problem with TB in certain parts of our communities." They can make their representations to the local NHS commissioning board far more powerfully, because it is far more local, and say, "Can we beef up on this? What can we do to improve this? How can we go about it, maybe with some screening as well as immunisation?" They can do that in a much better way because it is far more locally focused. That is a good idea of where the delivery of public health at local level could be hugely beneficial, drilling right down to communities and sometimes within wards.

Q299Chair: So you have no concerns, and the chief executive of Public Health England is a bit over-cautious, is he?

Anna Soubry: There is nothing wrong with being over-cautious. Duncan Selbie, being the man that he is, is quite rightly looking at every single aspect of what is a new brief. I would not say he is being overly cautious. I do not have a problem with people being cautious as we move into a new delivery of a system; so you should be.

Q300Simon Danczuk: A number of witnesses have told the Committee of their concerns about the preparedness of Public Health England and the NHS locally in the event of a national emergency. The head of Public Health England told us, "I will do everything I possibly can to make sure that people know whom to talk to from day 1." After that, Newcastle City Council said, "We do not know whom to talk to"; and Sheffield City Council went on to say that it was proving very difficult to get the answers they needed in order to advise them as a council. Are you comfortable with the preparedness in terms of a possible national emergency?

Baroness Hanham: I am going to leave that for the Department of Health, if I may, and then I will come in on local government.

Anna Soubry: I am going to hand over to Tim on that, because it is very important that we get the absolute detail and also know exactly where we are now.

Tim Baxter: As Duncan made very clear in his evidence, the people who are currently providing health protection services in the HPA just move across to PHE. They are staffing up the 15 PHE centres. It is very important that people know who will be the relevant people within the area teams and commissioning board, and that is being dealt with. I should also say that as part of the recent self-assessment process that local government has led, one of the areas they focused on was emergency preparedness, resilience and response. The general message was that people felt they were moving forward and they understood the new arrangements. There will be local health resilience partnerships on local resilience fora footprints. Not all of the leads for those have been appointed, but that process is going on.

You raise a very important point but it is very much one that has been gripped. Four regional exercises are being planned. I am not sure whether any of them have taken place yet, but they are planned to take place before the whole system goes live, to make sure people understand who they talk to and how responses will be made in an emergency. I think people are clear about the general architecture. The point is more about nailing down exactly all the people in the local resilience architecture, but the critical point is that local authorities do not change. They have their Civil Contingencies Act responsibilities, and health protection agency resources all move across to PHE.

Anna Soubry: There is also the role of the NHS. They are absolutely at the front and obviously they bear a large part of the responsibility. We should also not forget the director of public health in every local authority. As a Department, we have always recognised, as now are local authorities-I was going to say those out in the real world-and many others, the real role of the director of public health and the way he or she will sit within local authorities. Without being controversial, I hope and I genuinely believe that as politicians when we go back to our constituencies and political parties we are beholden to say to our colleagues that this is a real opportunity that exists. It is for the politicians to lead at a local level in their local authorities to make sure that their directors of public health, as I am sure they have done where they have been appointed-there are only a few vacancies left-are of the highest quality, and that they have the power, respect and status in the local authority that they should have given the job we want them to do.

Q301Simon Danczuk: Just for clarity’s sake, which Department has lead responsibility for ensuring that contingency structures are clear and transparent?

Tim Baxter: If the question is, "Who leads in a health-related emergency?" that is the Department of Health.

Q302Simon Danczuk: Which Department has lead responsibility for ensuring that contingency structures are clear and transparent?

Tim Baxter: The Secretary of State for Health has a duty to protect the health of the population, so in terms of the overall policy framework it is his responsibility to make sure that the legislation and guidance are clear. Then individual parts of the system all have their own responsibilities. For example, the NHS Commissioning Board has a duty to ensure that the NHS prepares for, plans for and responds effectively to emergencies and major incidents, which would be critical.

Q303Simon Danczuk: We are about 70 days away, Ministers. Can you give us an assurance that if there is a health emergency on 2 April, the new arrangements will be as effective as those that operated on 2 april last year?

Baroness Hanham: From the point of view of local government, as long as the directors of public health are in place-I think they will be because there are very few vacancies left-and the arrangements are coordinated, it is now in a good place to deal with any emergency. In reality, the number of national emergencies can probably be counted on one hand. These will be things that are happening locally; you will get a big norovirus outbreak, an outbreak of TB or something. It is terribly important that the local authority, local government and the public health director are together.

Q304Simon Danczuk: That is a "yes". You agree that things will be as good this year as last year?

Baroness Hanham: Yes.

Anna Soubry: I agree. One of the things that gave me great comfort-I was not a Minister at the time, but I learnt about it very swiftly after my appointment-was the real feeling within the Department that, because of the processes, structures and so on that had been set up for the Olympics, almost as a nation we had learnt a great deal about how to cope with the sorts of situations that might arise, so I am okay.

Q305Andy Sawford: The Committee is interested to know how much central guidance local authorities can draw on and who will be responsible for its production. We heard from David Buck of the King’s Fund. He talked to us about the impact of work being carried out on smoking. He went on to say that he thought Public Health England was in a very good position to make recommendations, advise and support local authorities in taking forward evidence. Similarly, we heard from Duncan Selbie of Public Health England who expressed a willingness to take on the role. He said, "We will be seeking to share the evidence about what works, not telling people what to do but opening up possibilities." What exactly are Public Health England, or any other agencies of your Department, going to do to make high-level policy and advice meaningful for local decisionmakers?

Anna Soubry: Smoking is a really good example of how this system could work. At the moment the Department of Health can do national campaigns. We can suggest that or say that this looks like a good idea; we can do what we have just done, which is to launch another campaign against smoking with an advert showing a cigarette turning into a tumour and so on, and with some success. When we did Stoptober we were very pleased with the take-up of the kits and so on. Smoking is an example where even better work can be done at local level. Under the guidance of PHE, who can provide statistics, advice and so on, because this will now sit with local authorities it means that in your area, and everybody else’s, the local authority can drill right down to ward level. You can identify an estate or development where you know the demography and you will have a very good indication from your GPs, linked with the health and wellbeing board, as to the incidence of smoking. You will have the power, political will and drive, which is a local decision, to target smoking in such and such a ward; to apply an order to make children’s playgrounds no smoking areas; to work with the local school and, at the same time, run a campaign there; and to make sure that all the pharmacies have got the right gear, that the GPs are stuck in on it and so on. Instead of taking a more blanket approach, although we target our anti-smoking work on particular demographics, you can do it so much better in a local area. It is under the guidance of PHE, often working in conjunction with the Department of Health, that the actual delivery will be even better, because it will be at such a drilleddown local level. Politicians, of whatever party, can seize this as a real opportunity and, come the next election, they will be able to put on their leaflets, "We have delivered this for you in our community".

Q306Andy Sawford: I have some questions about information sharing, but, on the first question, Baroness Hanham, what role does your Department see for itself and for any of the agencies within it, or perhaps organisations outwith government, such as the LGA, to support local authorities in this new public health role?

Baroness Hanham: I think Anna is right. The lead is going to come from the Department of Health, and it will be up to local government to make sure that the director of public health is concentrating very firmly and clearly on the local area and any local schemes they want to run. We would want to borrow from the Department of Health any advertising that they are doing and any campaigns that they have, and take those locally as and when appropriate. The health and wellbeing boards will be crucial in deciding what needs to be done and where, so from the Department’s point of view we see this being passed down to local government but with local government being given the strength to know that it can take advantage of what the Department of Health is doing.

Tim Baxter: PHE will be crucially providing evidence and data at a very granular level, so people will be able to see at ward level, for example, how they are doing and compare themselves with comparators and then, as the Minister said, provide health expertise and so on, but we will not be in the business of lots of prescriptive central guidance, which was the point Duncan was trying to make. We are there to help, encourage and so on but not to tell.

Q307Andy Sawford: On the point of data-sharing information, we have looked at Caldicott and so on, but Kent County Council said in its evidence that "a crucial outstanding issue relates to information governance and the ability to share nonpatient specific information between the NHS and local authorities." Yet, in your remarks you are assuming that that is relatively straightforward and it will work. It is an assumption on which the relationships among Public Health England, local authorities and health bodies is based. Perhaps you could say what your Department is doing to break down the barriers that local authorities have told us they perceive between the organisations in the health arena.

Baroness Hanham: Can I just intervene on this? Information sharing across government and Departments is fraught. We could spend the whole day discussing information sharing. Everything I go to has the same problems, and it is an issue. The issue is that local authorities do not know what they can pass on to the health service. If somebody comes into the A and E department, for example, the NHS has no idea whether it can tell somebody. We were talking earlier today about people who are sexually assaulted. The health authority does not know whether it can pass that information back to the police, for example. There is a huge area here that we need to get to grips with in government. We need to involve the Information Commissioner, but the whole issue of information sharing, particularly now within the Department of Health and public health, will hold us up.

Q308Andy Sawford: Local authorities will be pleased to hear you being so frank about that challenge, but they would want to know what you, as the Minister, are doing to address it given how far down the line we are in implementing the health and wellbeing boards.

Baroness Hanham: We are quite a long way down the line of discussing it. Look at some of the issues, like community budgets. It does not sound very relevant, but every single aspect of what has to be done in the community budget needs information sharing. My Department is talking to every single Department that would be involved in community budgets about the problem of information sharing. We are all doing all we can to open it up. I think we ought to have a national view across government as to what we can do in terms of giving advice about the information that can be shared.

Anna Soubry: Speaking very much with my Department of Health hat on and now sounding a little bit obstructive, as other Departments might seem, confusion often arises; when we talk about information sharing, we all get quite agitated in the Department of Health because often we think that means names, addresses and medical details. I am sure that at that point everybody says that we are not talking about that, because we all understand and agree that there is an important bond between the medical professional and the patient of absolute confidentiality.

Q309Andy Sawford: That was why my question was about non-patient specific information; that is what we would like to hear about.

Anna Soubry: You are absolutely right, but a good point made at an earlier meeting, I think by the Home Secretary, was that often you can share information where the details of the person are anonymous. For example, if you are in an A and E you can say that last night five women presented who claimed they had been victims of domestic violence. You do not need to know their names and addresses; you just need to know that five presented. You might need to know some of the detail of the injuries; you might even need to know where they were in a particular area. Nevertheless, the problem is that, frankly, at times there is a lot of ignorance; there is also often a lot of resistance to sharing information, but it comes in different ways.

On your point about non-patient specific information, one mistake we often make is that the real test should be about outcomes. In cardiovascular work, one thing we have seen-it may have been under the last Government, but none of this is anything to do with party politics-is that in order to drive up outcomes so people got the very best treatment we began to publish what was going on. While that is very interesting for actual and would-be patients, in truth the real driver is the rivalry between surgeons. I used to be a barrister and so I was a professional. There is no greater drive in any profession than the thought that so-and- so might be doing a better job than you and it is out there in the public domain, so we are going to publish outcomes. As Tim has explained, we can get down to interesting levels, such as CCG level. Therefore, you as the local MP could say to your CCG, "Hang on. Why are you not doing as well as that one?" and then you can go to your councillors and say, "Guys, why is this happening and why is that not happening?" and get the health and wellbeing boards to start to drive things as well.

Q310Andy Sawford: That is an indication of how you might monitor or measure performance, so when might you intervene on poorly-performing health and wellbeing boards? What might trigger an intervention, and what form might that intervention take? What you have described sounds somewhat like the comprehensive area assessment of a few years ago and the ability of the public to see by the collection of data from local authorities the performance in a particular area of work.

Anna Soubry: I am talking about the publication of outcomes drilled right down to CCG level. In any event there are enough systems in place to monitor what is going on in the delivery of health care under the new system. I do not think you would have health outcomes coming from the health and wellbeing board. It is the job of the health and wellbeing board to look at the outcomes in their area and start to take action, if they need to.

Q311Andy Sawford: But will central Government intervene if there is poor performance?

Anna Soubry: At what level?

Andy Sawford: At a health and wellbeing board level.

Baroness Hanham: Performance monitoring is going to come partly through the local authority. All of them will have health scrutiny committees. They will want the information in their local area. The director of public health is going to need to know what the comparisons are across the piece. He will need to know to report that back, so the local authority will have a really significant role here in doing the scrutiny and monitoring.

Q312Andy Sawford: If a health and wellbeing board is evidently performing poorly relative to other health and wellbeing boards, you do not envisage an intervention being made?

Baroness Hanham: In this case, it would not be the health and wellbeing board; it would be the director of public health who would be responsible for making sure the scrutiny committee knew. We need to be really clear that the direction from the centre is going to be light touch; it is for local authorities and local CCGs to apply their own standards.

Anna Soubry: But you have still got Public Health England.

Q313James Morris: Tim talked about central prescription. Do you expect to have less central guidance coming out in this area-50% less, 80% less?

Tim Baxter: I have written quite a lot of the stuff that has been published in the last two years. Generally, we are trying to move to a place where there is a pull for it, if people at local level say, "It would be really helpful if you gave us guidance on X, Y and Z". Indeed, on the data issues we published guidance on the local public health intelligence system back in September, so if there is a demand for it, yes, but increasingly we are trying to coproduce it-to use a horrible phrase-with the Local Government Association and others and so make it something that people find useful.

Q314James Morris: With all due respect, DCLG’s definition of "light touch" may be different from that of the Department of Health who historically may have had a culture of wanting to prescribe parameters, not really subscribing so much to the philosophy of localism.

Tim Baxter: I have been in the Department of Health for 21 years, and it is true that historically the relationship we have had with the NHS has been a more top-down prescriptive model. However, we are moving to a new system and the relationship we need to build with local authorities fits in very neatly with the relationship we need to build increasingly with other parts of the health and care system, such as the NHS Commissioning Board, which cannot be directed by the Secretary of State. I would certainly appreciate that we definitely need to learn different ways of working.

Baroness Hanham: Prescription has gone, but, for example, the Local Government Association is now doing more and more in advising local authorities on having a grip on what they need to do and then mentoring and helping them through. That is probably where we see most of the influence coming from now, because that is not only one local authority; it is a number, and in bringing together all the things that have been raised by local authorities, they are going to be able to iron them out more or less for themselves.

Q315James Morris: Picking up Andy’s point, the central test will be if there is a significant systemic failure at some point. Anna, would you be able to resist intervening ministerially in a situation where it is clear there has been some sort of systemic failure?

Anna Soubry: Would it not be the same as a systemic failure in the local authority that could happen at the moment? I have already mentioned directors of public health. Directors of public health have their own professional body and standards. They used to work in the NHS and now they are moving over to local authorities. Obviously, they will not be standalones because they will be working for the local authority; they will be accountable to the chief executive and other senior officers and so on, but in the interests of public health they will attend the sorts of seminars or conferences you would expect them to attend. There will be that sharing of information and a desire-I have no doubt, based on conversations I have had with a number across the country-to drive forward success within their local authorities. Like many people who work in local authorities, in my experience, at a senior level they are proud of their local authority; they want it to do well and make sure it succeeds. I am confident that that sort of attitude will now be engendered in the delivery of public health. Do not forget there is also the role of Public Health England in the guidance it can give and all the checks and balances they put it into it.

Tim Baxter: The important point about the role of the local government sector and the sectorled improvement, which has been working in children’s service and adult social care, is that they do not want to see this fail, and peer improvement is very powerful. The alternative, if you rush into central intervention, is that you have to own the problem at the centre, which is not a very comfortable place to be. As the Minister has said, local people wanting to do a good job and the support of Public Health England and the local government sector will be very powerful.

Q316Chair: I understand that we hope everything goes well and that authorities perform well and public health is delivered well at local level. If things are not going quite so well, we hope for peer assistance through the LGA. Public Health England is there to offer guidance. If things go really badly wrong, and despite all this guidance and help they are not being put right, whose job is it to say, "We need to do something about it, and it is our job"?

Tim Baxter: The local authorities are statutory bodies; it is their responsibility to manage themselves. If they are not managing we think sector-led will be the way in which issues will be raised. In the final analysis, central Government can intervene, but that is a very heavy stick that is very rarely used. The evidence we have seen is that where sector-led improvement and Public Health England can increasingly spot problems early and put in support, that is the likeliest way of sorting out problems.

Q317Chair: I agree, but if it does not work is it the job of Public Health England to say to Ministers, "We’ve tried; it’s not working, and we need to do something else"?

Tim Baxter: Yes. If it was a matter of central intervention, obviously we would need to be talking to DCLG as well.

Anna Soubry: To make things absolutely clear, as things roll out after April my relationship with Duncan Selbie is such that we have meetings and those will continue. They are separate; they have their own role to play and they do not want Ministers bossing them about and telling them what to do. On the other hand, there is an absolute relationship there which in my view is absolutely critical.

Baroness Hanham: The idea that Ministers are going to get involved, unless there is an absolute crisis, is probably unreal these days. Local authorities now are accustomed to managing themselves for every service for which they have a responsibility. They do not get people crashing down on their heads every five minutes. Even if something goes very seriously wrong, they are by and large helped to sort it out. The Department’s role, if something went really wrong, would be to liaise with the Department of Health and between them give advice and help, but it would not be dictatorial; it would be to say, "Who would be the best people to help them out?" whether it is peer help or peer monitoring. If it is a wholesale disaster, I am sure the Departments would have to intervene.

Q318Bill Esterson: In circumstances where national Government intervention becomes essential, have you put in place ways of rolling that out and how you will communicate with the local authorities? Does that structure exist between the Departments and local authorities?

Tim Baxter: Various legal powers would need to be invoked.

Q319Bill Esterson: It is a formal process?

Tim Baxter: There would be a formal process. If you would like a detailed note on this, we are very happy to provide it. Coming back to the power of informal arrangements, if the chief executive of the LGA were here she would say that what the LGA can do as peers, without any formal powers but through the power of suggestion, is a lot quicker than what central Government can do, and arguably, certainly in the short term, a lot more effective.

Bill Esterson: Do you have anything to add?

Anna Soubry: No.

Q320Bill Esterson: Coming to the point about the balance between prescription and persuasion, when the Health Committee looked at smoking it found that the ban on smoking was effective, whereas lifestyle initiatives-Dr Mike Grady made this point-were ineffective, certainly with the bottom 50% of the social gradient of health. Do you accept that there are some public issues, whether it is smoking, alcohol misuse or obesity, that may inevitably require central Government action, including legislation, as the only effective way of changing behaviours in the population? If local authorities are to make a big difference to the health of the population, is the money going to be available for them to follow through on that sort of legislation?

Anna Soubry: If legislation is passed the money must follow; otherwise, the legislation would be meaningless. The debate between legislation and persuasion is a really good one to have. No doubt this is not the time to have that debate.

Q321Bill Esterson: Do you accept there are times when it works?

Anna Soubry: Absolutely. I was always very sceptical about the ban on smoking in open places, but I was a smoker. I was proved absolutely wrong. The way we have changed as a nation and the whole cultural attitude towards cigarettes is phenomenal. Every time you see a film where everybody is puffing on a fag you think, "My God. Did we actually used to do things like that?" We did. Banning smoking in restaurants was one of the huge achievements of the last Parliament. Today, we have shown that the incidence of asthma in children has plummeted. All those people who voted for the smoking ban can say they played their part in reducing asthma in children, because we think it is directly related to the ban on smoking in open places. As you know, our consultation about standardised packaging of cigarettes has finished, and we are now waiting for the evidence to be published. Unfortunately, if I had a view I am not allowed to share it with you. You did notice I said, "If I had a view". You are not allowed to have a view; those are the rules, and all the rest of it. You get judicial reviews and all sorts of things. If there is a proposal it would have to be legislation, and that would go through the usual process; it would come before Parliament and debate would be had. I cannot talk about that, but I can talk about minimum unit pricing.

Bill Esterson: I was going to ask when you were going to do that.

Anna Soubry: I am more than happy to talk about it. It is a matter of public record that I was very cynical about it; I thought it was a pretty average idea, even though it was put forward by my Prime Minister. I was not convinced of the argument. Then I met a whole load of liver specialists and doctors who, in terms of argument, frankly blew me away and completely convinced me that it is a thoroughly good idea. I am allowed an opinion because it is a Home Office lead, not a Department of Health lead, and I am absolutely up for it.

Q322Bill Esterson: Do you know when it is going to come in?

Anna Soubry: No. We are consulting at the moment. The consultation finishes on 6 February. As a constituency MP, I publicise it in my constituency and ask my constituents to write in and join in the consultation, because there is a good debate to be had about it. I am in favour of it, and I think it will have an influence on drinking habits; certainly that is the view of doctors.

As to obesity, which you quite rightly touch on, at the moment we are trying to work with industry, getting them to sign up to something called the Responsibility Deal whereby they undertake to do certain things, like reducing salt. That is one of the reasons we have some of the lowest salt levels in the world. Our levels of trans fats in food have come down to just under 1%.

Q323Bill Esterson: But the real issue is sugar, isn’t it?

Anna Soubry: I struggle with the idea of not allowing children’s cereals to have more than a certain percentage. I am an old lawyer, so my first question would be: do you mark cereal packets "Adults only"? Then you stop mothers at check-outs and say, "Excuse me, Madam, but are you buying that for your own consumption or will you give it to a child?" But seriously, you can see the logistical issues of making that happen. Let’s say you said that cereals with 30% sugar should be banned. The danger is that for those at 29%-Mr Stevenson gets the point already-people say, "It’s all right. The Government haven’t banned it, so you can have three bowls of it." One bowl of sugary cereal will not do you any harm if you have it once a year, but if you have it as part of a diet that is full of other sugar, fat and other rubbish and too many carbs, obviously it will do you a considerable amount of damage. That is the problem when you start to micro-legislate in that way. I am not saying that at the moment the Responsibility Deal is perfect by any means; it needs a lot more beef going into it.

Bill Esterson: Beef does not have sugar in it.

Anna Soubry: Beef with sugar-that is quite a good concept. The debate that was had, even if it was in the press and it was a short one, was a good one in the sense that it fired a very big, loud shot across the bows of manufacturers and retailers. It says to them, "You know what? If you don’t get your house in order, we may well legislate."

Q324Bill Esterson: So if the manufacturers just carry on as before, you will legislate?

Anna Soubry: At the moment, we have a carbohydrate or calorie Responsibility Deal, and so far a good number of people have signed up. In terms of our Responsibility Deal, some people have not signed up to the right things. For example, Greggs are not signed up to the salt Responsibility Deal. If they are, I apologise to them. I have asked for meetings with some of the high street suppliers of good fast food, except that some of the food they produce has the sort of stuff in it that is not great for this nation’s health, and I want them to sign up to the Responsibility Deal. A bit of naming and shaming is going to start to happen, because we make it clear that, unless we begin to see substantial changes, we will consider legislation. At the end of the day, the ultimate responsibility has to be-because it is-of each and every one of us, especially what we as parents feed to our children. The state can do only so much.

Baroness Hanham: It picks up the point as to whether the directors of public health are going to have responsibility for education. I do not mean general education but education of the public on things like obesity and drinking. It takes a long time to get legislation in place. In the meantime there is definitely a responsibility to make sure people understand what the difficulties, limitations and dangers are. That will fall squarely on the directors of public health.

Q325Bill Esterson: Mike Grady told this Committee that these initiatives do not work for the bottom 50% of the social gradient of health. While what you say is great when it comes to personal responsibility, what about those people who do not take the responsibility?

Anna Soubry: But you cannot have fat police or sugar police, which is the next logical step. On salt, we have achieved some of the lowest levels in the world. We are very proud of what we have achieved on front-of-package labelling. For the first time ever, all the supermarkets have agreed to have a standardised form of the traffic lights, but I accept that it is only as good as the ability of somebody to read it and then, most importantly, act on it. As politicians, you cannot tell people, and certainly cannot force people, to eat a healthy diet. You can make sure they are properly informed and encouraged to take responsibility for their diet. In my own constituency I already have schools taking this really seriously and working with parents. One of my schools had a week of just cooking and looking at food, with all the children in the school, and the parents came in to help in the classes to learn how to cook. It is small stuff, but I honestly think that is the stuff that will be delivered in these changes in public health.

Tim Baxter: It also comes back to the director of public health trying to use what is available nationally and targeting. You are absolutely right that with the more hardtoreach groups you are going to have to do different things; you have to be more imaginative and probably put a bit more resource into it and do things differently, but that is part of the strength of the director of public health in local authorities.

Q326Bill Esterson: Finally, the Cabinet sub-committee on public health was disbanded on 8 November on the basis that it would allow public health issues to be discussed and decisions taken by a wider group of Ministers across government. Can you say how many times and by what mechanism this has happened since the sub-committee stopped operating?

Anna Soubry: I do not know of any.

Q327Bill Esterson: Do Ministers know that is supposed to happen?

Tim Baxter: We have plans for engaging with the Home Affairs Committee. The brutally frank answer is that we have not done so yet, but the advantage of the Home Affairs Committee is that that brings together the same sort of range of Departments as the Public Health sub-committee at Secretary of State level, and it is a very good forum to drive through public health. One of the challenges for us in the next couple of years is to use that effectively. There is also a senior officials group that is chaired by the director general in charge of public health in the Department, and the Minister meets her colleagues on a bilateral basis.

Anna Soubry: I do. I went to see Edward Timpson in the Department for Education to talk about sport, for example. One of our Responsibility Deals is about physical exercise-we cannot call it sport-and the lack of physical activity in too many of our youngsters. I went along to talk to Edward Timpson about that and what could be done about funding, initiatives and so on.

Q328Bob Blackman: Minister, no doubt we will see you at the inauguration of the national kebab awards later.

Anna Soubry: Mr Blackman, there is nothing wrong with kebabs, as you well know. Mr Blackman and I go back over 30 years, so it is not a new problem, is it?

Q329Bob Blackman: One of the frustrations that I experienced as a councillor before being elected here was having targets thrust upon us by central Government to say, "You will get this number of people to cease smoking, and you will get money as a result of achieving that." I note that the data will be available, and that is good news, but have you got any concerns about the role of councillors and local councils in encouraging smoking cessation, reducing alcohol dependency and so on? Have you got any concerns that people will be able to do this?

Anna Soubry: Of course I have concerns at an individual level that perhaps some councillors will not get it, to put it in those terms, but two things give me heart. One is the appointment of the directors of public health who will be the leads, the steers, and who will be putting the evidence in front of a council and saying, "Look, just look at our smoking rates and obesity levels, and look at it in your ward, councillor." I am not saying they will be as aggressive as I am being, but that is the evidence they could put forward, and make the case to councillors who will know and understand their statutory obligations and duties in any event through all the various mechanisms we have described. They give me good heart.

The other thing that gives me heart is I honestly believe that, as this begins to unroll, being the political animals that we and a large number of councillors are, we will begin to see it in the same way. I may be wrong-you will tell me if I am-but they have got recycling. I confess, Mr Betts, that I am one of those who helped my councillors write a leaflet about recycling rates in my borough versus the recycling rates in another borough, championing the rates in the other borough that happened to be controlled by my political party and criticising my local borough council because it was another political party. I am not saying it became a competition, but it almost was. You could see that politicians suddenly grasped the fact that there were really good reasons for increasing recycling rates: first, because it was a really good thing to do in any event, but, secondly, the public liked it and got it, and it could be an important feature.

Q330Bob Blackman: I agree with you on the point about recycling, but the key challenge coming here for councils is that you knock on the door and say, "I’m telling you you have got to give up smoking, and, by the way, you’re overweight; you’ve got to take more exercise, and will you vote for me on Thursday?"

Anna Soubry: No; you would never do that.

Q331Bob Blackman: There is a clear dilemma here for people at a local level, who clearly can encourage healthy lifestyles. There is a challenge particularly in the areas we are talking about where people are going to be reluctant to take the message.

Anna Soubry: Yes.

Q332Bob Blackman: Is the Department of Health or DCLG putting information in the hands of councillors and councils on the type of initiatives they could launch and assisting those campaigns?

Baroness Hanham: This is going to become very important. There are enough councillors who are interested in health. Bringing the director of public health back into local government has been very widely welcomed, for the reason that local councillors can get involved now in a much more local way in the sorts of initiatives that we are talking about. Local councillors who are interested will probably need some training, but that will have to come from the local councils themselves, although I am certain that training programmes will be set up that they can take advantage of. It is just making sure that that encouragement is there and is not directional. I do not think there is any point in us sitting in the Department for Communities and Local Government and saying, "You will have a training scheme". Local councils themselves will say, "We don’t know enough about this; we need to find out." I am confident that this is a popular enough policy to get local councillors engaged in what is going on. I also think that there are problems of deprivation in all local authorities. There is a variety of things-poor housing and poor eating-that nobody has known how to grip, and probably having this localised will make it much easier.

Anna Soubry: Nobody in their right mind would ever knock on anybody’s door and say, "You’ve got to stop smoking", and all the rest of it. It does not work like that, but what the Baroness has just said about health inequalities, for example, would be a huge driver at local level. I went to Coventry to see a project and met a number of people right through from local councillors to the director of public health. They told me about the huge inequalities in health in Coventry and their absolute determination to reduce them. Then they showed me what they were doing at a local level. This was just simple stuff in a local library, bringing people in from different communities and doing some work with them on all sorts of things. It is a great opportunity, as the Baroness quite rightly said, and it has been greeted in a lot of areas.

Tim Baxter: On the particular issue of smoking, ASH-Action on Smoking and Health-has produced a guide for local authorities on some very practical steps they can take.

Bob Blackman: I know; I launched it as secretary of the all-party group.

Tim Baxter: There is a lot of really good guidance like that, and it is really good that that has come from the voluntary sector; it is not a central Government prescription.

Q333Chair: If we turn to the guidance around on the system, last year the Department of Health said to local authorities that it expected them to ensure that partners, including the NHS and Public Health England, had effective health protection plans in place. There was a clear onus on local authorities; it was their responsibility. But the regulations we have now seen say that local authorities should provide only information and advice to partners. It is a watering down of the language. Is it a watering down of the responsibilities of local authorities in this regard?

Tim Baxter: The regulations reflect the legal range of responsibilities, as one would expect. The Secretary of State has the duty to protect the health of the population. The duty on local authorities is to take steps to try to ensure, in effect, that plans are in place. What the local authority cannot do is require, in the sense of legally insist. If they decide that an NHS trust, or whatever, is not doing what it should do, they can raise the issue with that trust, but the regulations also say that they should advise Public Health England who fulfil the health protection duty on behalf of the Secretary of State. The regulations are saying that you escalate the issue to the person in the system who has the final responsibility for protecting the health of the population.

Q334Chair: What we are saying is that the Health and Social Care Act was not written in such a way as to allow the initial intention of a responsibility to ensure on behalf of local authorities to be implemented.

Tim Baxter: If you read the guidance in that very literal way, it is perhaps slightly unhelpful. I take responsibility for that. I drafted that. I am quite happy to say we will look at it again. We have already said that we will look at the guidance in the light of the regulations. The way that the Act is drafted means that, as we say in the guidance, statutory bodies retain their responsibility to respond to the advice and challenge they receive. The point is that if they ignore advice they are receiving from a public health professional they had better be pretty clear that they are doing it on the right basis.

Q335Chair: But basically it amounts to the fact that you would have had to write the Act in a different way to enable that "ensuring" role to be implemented.

Tim Baxter: It would not have worked, essentially, because the Secretary of State has the duty, and then in effect giving 152 local authorities almost a similar duty would not have worked. I think my colleague will back me up.

Q336Chair: So it is not quite as localist as we might have thought it was?

Tim Baxter: For some things it is right for central Government to be responsible for protecting the population, because there are all sorts of threats. There are lots of things we can do to protect ourselves. Washing your hands frequently is probably the single most important protection against infection, but there are lot of things where it is central Government’s responsibility to ensure that the population’s health is protected. It is right that the Secretary of State has that final responsibility and duty. The role of the local authority, giving them this duty to advise and challenge, is to make sure that the director of public health sitting in a local authority has a clear function in relation to health protection; otherwise, he or she would not have any clear role in health protection. The public health stakeholders whom I have talked to about this for the last two and a half years are very clear that they like the fact that the director of public health will have a responsibility around health improvement, commissioning services and so on, and giving advice to clinical commissioning groups, but also will have a role in health protection.

Q337Chair: But it is about advice and information, so it is slightly more nebulous in terms of responsibility.

Tim Baxter: I come back to the fact that if you are advised by a highly trained professional who knows what he or she is talking about that arrangements you have in place to protect the local population are not secure, reasonable and robust, that is a fairly clear and influential bit of advice.

Baroness Hanham: It is important that we position the director of public health in the right place in local authorities.

Chair: I was going to ask about that, but please go on.

Baroness Hanham: The director of public health needs to be answerable to the chief executive, if possible. Some local authorities will not work like that; they will have slightly different arrangements, but the director of public health has got to be at the top of the tree and able to direct or advise on all the other aspects of local government. He is going to take in housing, social services, education, waste and all the rest of it. He has to be in a position where people listen because he is at such a level that they cannot ignore him. We hope and expect that all local authorities will have the director of public health at the second tier under the chief executive, at the very least.

Q338Chair: But if they do not, essentially that is a matter for them, is it?

Baroness Hanham: It is a matter for them, but any authority with commonsense will want to make sure that the director is in a position to take the blame, if nothing else, at that level.

Q339Chair: I am very much involved in national parks. I know that the English National Park Authorities Association wrote to the Department of Health as part of the consultation about the guidance to health and wellbeing boards about what issues they should take account of. They asked that in relation to the offer available from national parks, particularly in terms of healthy living, outdoors and that sort of thing, the health and wellbeing boards should be statutorily obliged to take account of that in drawing up their strategies. Is that something the Department has had a look at or has a view on yet?

Anna Soubry: I do not know whether they looked at it. It is a great idea, but we always get a bit nervous about putting statutory duties on people when, at the end of the day, we are all about localism and letting health and wellbeing boards determine their own composition and work, based on their own strategic needs assessment of their area.

Q340Chair: Guidance is going to be issued to health and wellbeing boards about what they should look at, so is one of the things they ought at least to consider looking at the role of national parks?

Anna Soubry: It sounds like a good idea to me.

Chair: If you have not got an answer now, is it possible to give us a note?

Tim Baxter: I do not think we can give you a categorical answer to that one way or the other.

Baroness Hanham: In reality, if you make it a statutory responsibility by definition it means you have areas of outstanding natural beauty everywhere, and you do not. They are going to be related very much to authorities that border them, or you may be able to take children out to them on a daily basis, but they have to be within reach, so a statutory responsibility might be a bit tricky.

Q341Chair: I am referring to guidance; that is all. Perhaps you could have a look at that.

Anna Soubry: You have raised a very good point in the public arena, and we shall take it away.

Q342Bob Blackman: Moving to the financing of this, the final settlement seems to have increased by about 20%, which is quite a large increase on the original proposal. Why is there such a big increase?

Tim Baxter: Last February we published estimates of what the baseline spending on public health would be. At that time we knew that it was not going to be completely right, partly because of late changes.

Q343Bob Blackman: The baseline was 2010-11, was it?

Tim Baxter: Yes, but uplifted to allow for inflation. We knew, because of late changes to responsibility for commissioning for abortions and sterilisations, that there would need to be some changes. What the publication of the baseline allowed the people to do was then, in various places in the country, say, "No, that cannot be right". We had actually done two surveys before then. The first survey we thought, "No, these cannot be right. There are too many implausible zeros." We did the survey again and it was better, but still we knew that it was not going to be right. What you see with the increase in the baseline is a very constructive process of local authorities working with their PCTs saying, "Let’s get this absolutely right". We have now reached a point where the baseline has increased to £2.5 billion, roughly, and that is as accurate as it is going to be. On top of that, Ministers made the strategic decision that they wanted to put more money into prevention.

Q344Bob Blackman: Witnesses have suggested that actually there was a reduction before 2010, where money was being switched out of public health into other health programmes. Did you have evidence of that?

Tim Baxter: I would say that whatever year you took, somebody could say, "That is the wrong year because we just made a decision that we were going to defer spending", or something like that. It would have been swings and roundabouts. There might have been some things happening in some areas that made 2010-2011 not a great year. Equally, in other areas, it might have been the reverse. Overall, it was a process that allowed us to get as good a sense as humanly possible of the baseline for public health. As I say, we did promise we would look at representations from local authorities around the baseline, and we did. It is actually very good news.

Q345Bob Blackman: Obviously, the announcements were made on 10 January, 79 or 80 days before local authorities take over responsibility. Local authorities always complain that they do not get enough money, but when they get a huge increase like this, without the expectations, at such short notice, it does cause problems in terms of planning what work they can do. What are the Departments doing to assist local authorities to make sure this money is spent wisely and with good value for money?

Tim Baxter: We have been working with local authorities right from the word go on this process. We would have liked the settlement to have been announced before Christmas but because it was a two-year allocation that was not possible. The principle of localism is, of course, that local authorities should make the decisions and we are not going to tell them exactly how to do it. We have published guidance around various things. There is a lot of working going on with the Public Health England transition team and Local Government Association, working with local authorities. So, where people need assistance and help, generally speaking, that is there. What is very pleasing is that the general reaction to the allocation has been very positive from the Local Government Association, from SOLACE, even from the Local Government Chronicle and, indeed, from public health stakeholders.

Q346Bob Blackman: What about making sure that there is proper value for money for the spend?

Tim Baxter: That is interesting because I am not aware of any local authority saying, "You have given us far too much money. We cannot possibly spend it."

Q347Bob Blackman: One of the problems is that if you give people lumps of money at relatively short notice there is a panic view that, "Oh, we must spend this money", and you do not necessarily get value for money.

Tim Baxter: They do not have to spend it all.

Anna Soubry: There is a ringfence.

Tim Baxter: It is a ringfenced budget. They can put it in a public health reserve. It is a good point but they do not have to spend it all in, say, 2013-2014. The fact that we have also got that twoyear allocation, and that capacity to carry it over, means that I do not think that the problem that you have identified should be a major issue.

Q348Bob Blackman: At the moment, the money is ring-fenced. It is ring-fenced for the first two years. A lot of the witnesses have said, "Actually, we would much rather want it communitybased or placebased, rather than ring-fenced". What are the Government’s plans for changing the position?

Tim Baxter: There are no plans in this spending review. It is an important point that the money can be pooled; that is specifically in the grant conditions. We are very much wanting to learn from the community budgets work that has done a number of pilots looking at health and social care. That is the short answer. Baroness Hanham may want to add to it.

Baroness Hanham: Yes, local government does not like ring-fenced grants, as you know very well, but I think it sees the advantage of having it ringfenced at the moment, until things begin to work out as to how this whole area of public health is going to work. I would expect and hope that in due course it will become unringfenced. As you were saying, with things like community budgets where everything is slightly different because every area you are working in has different priorities in different areas, it will make sense. I am sure that, for the Department for Health money, they will decide where they are going to put it. I think actually you pass it to local government to parcel out, because that is part of the grant.

Q349James Morris: You said that, under the arrangement, the grant will be able to be pooled? Could you explain what you mean by that?

Tim Baxter: Pooled with other budgets.

Baroness Hanham: Yes. It also means pooled across local authorities, because in some areas the director of public health will not be the director for just one local authority; he will be director for maybe two or three. If you taken Kensington, Hammersmith and Fulham, and Westminster, they have got one director of public health for all three local authorities. The money can come in and be pooled to help across the three authorities.

Q350James Morris: I detected some degree more enthusiasm from you, Baroness, than from the Minister with regards to the potential of this being a place-based budget. Does it not make a lot of sense to think about this in terms of place and community budgets? I will give you an example of particular interest to me, which is mental health. Mental health might generally not be defined as an issue that is related to public health but clearly, if we get mental health policy right, that is going to have a very direct impact on public health in terms of early intervention and so on. There are clear linkages for which it would surely be better if they were expressed in terms of the way that the funding is allocated. For example, some of the money that goes into public health could be used-off the top of my head-to improve local community mental health services.

Baroness Hanham: The Total Place plans that are happening now have demonstrated that actually budgets that are fluid are really very helpful. They can be used to influence. On your point about whether mental health comes into it, mental health at the moment is not public health; it is health. You would have to be looking at mechanisms such as education to bring that in. Certainly, to have a budget that can be used across a wide spectrum, even within public health, is going to be very valuable.

Anna Soubry: Can I just pick up on this? Of course, if you look, say, at smoking, one of the most difficult groups and one of the groups we know smokes more than other groups comprises people with mental health issues. We also know that alcoholism and mental health are extremely linked. It is thinking out of the box. Because, if you are looking at smoking, as a local authority, right down even into a ward level, you might say, "Actually, let us look at people who have mental health issues. We want them to stop smoking because we want them to be better all round." So there could be real work to be done there, which would normally be called mental health or smoking, but actually it is completely interrelated. Local authorities have the freedom to think in a way that frankly we have never thought of, as a Department.

Q351James Morris: Would it not be better if the way the funding worked reflected precisely the point you just made?

Anna Soubry: Exactly, because you will have a budget for public health; if you then decide to do some work on smoking with people who have got mental illness, you are already looking at mental illness. You are looking at it in a different way but you will still be achieving the same sort of results, which is to improve the services for people who are mentally ill and reduce smoking.

Tim Baxter: There are not any insuperable barriers to people actually sharing money around. With the ring-fenced grant, there are reporting arrangements; they are pretty lighttouch. People can share the money across and, as the Minister said, look at using the money in innovative ways. It may be worthwhile to rehearse why the Government ringfenced public health money. Essentially, they want to protect spending on prevention, because the experience in the NHS was when your local acute hospital was in trouble, the public health funds would be raided, to put it crudely. Also, the Government wanted to be very clear that it was meeting is commitment in realterms spending on the health budget. The funding mechanisms are obviously very important but the shared objectives about how the money is spent are the most crucial thing.

Q352Andy Sawford: I have some further questions about the funding formula. There has been some criticism of the use of the standardised mortality ratio in the funding formula. David Buck of The King’s Fund told the Committee that the standardised mortality rate "tells you a lot about past problems in local authorities, but there is a real question about whether it tells you about the current problems" because behaviour changes. That struck a chord with me because the behaviours of people in their sixties and so on, who fall within the current formula, will be quite different from that of people in their thirties and so on. I wondered how you thought that you could address that concern about the current behaviour being reflected in the funding formula.

Tim Baxter: In terms of the funding formula, the Minister has asked the Advisory Committee on Resource Allocation, which has a long history of doing allocations in the NHS, to look at this. The fact is that in the NHS we have very good data on health services utilisation, so we know that someone in their eighties will use something like 20 times as much health service money, on average, than someone in their twenties. We do not have that for public health. When we consulted a couple of years ago on what the best basis for the allocation was, the general response was that an outcomebased measure, like the standardised mortality rate for the under75s, was probably the sensible way to go, simply because better data was not available. The SMR for under-75s correlates very well with deprivation. Also, you get the data down effectively to ward level, to middle super-output level. You can then get very granular about identifying the most deprived parts of the population and directing more resource to them.

Q353Andy Sawford: Westminster Council, for example, have recommended to us that we use the deprivation index. Why not do that?

Tim Baxter: The short answer is that ACRA looked at it and felt the best data source to use was SMR. This is not to say that this is a longterm solution. They were very clear that-

Q354Andy Sawford: They were not clear, actually, were they? What they told us was that health outcomes should not be the main driver because a local authority that improves its health outcomes would be risking losing future public health funding. There is a perverse incentive.

Tim Baxter: Yes, there is. ACRA know that and they want to do further work to try and get to a better-

Q355Andy Sawford: Will you review it?

Tim Baxter: Yes, absolutely.

Q356Andy Sawford: What is the timetable for a review of the formula?

Tim Baxter: They will be starting to look at it over the coming months. I could not tell you, sitting here today, when there will be a new formula. What I can say is that they are aware of the weaknesses, but it was a pragmatic decision that this was the best data that they have got, that correlates with deprivation and that gives data down to a very small area. They recognise the issue about the perverse incentive that, if you do really well, your money might get cut, and that you need a base level of investment to keep the outcomes for the population at the same level or improving.

Andy Sawford: I think the Minister was going to come in.

Anna Soubry: No, I was not. I was nodding in agreement.

Q357Andy Sawford: There was one additional point that has been raised to the Committee. We had Cllr Nick Forbes from Newcastle, and we heard from other local authorities, such as Westminster, that, particularly on sexual health services, the services that they provide cater for a much wider population. What they have asked is whether there could be a way of recognising nonresident service users in the formula.

Tim Baxter: ACRA looked at that, and they found that the only local authority in the country where non-resident users of population was significant was the City of London, for obvious reasons, and they did not want to make an adjustment for that, because, in effect, you then lock in the existing provision levels. If a particular local authority is providing lots of sexual health services, it gets more money to do that, but then the authorities whose population is being treated in that place do not have an incentive to build up services themselves. ACRA decided that it would be better to try to give local authorities evidence, as far as possible, on patient flows-we have some good evidence on that-and then they should look into recharging arrangements, which in London they are doing.

Q358Andy Sawford: So you would look at recharging. The evidence that we have is that it is not just the City of London but other local authorities.

Anna Soubry: Certainly, if they are pooling, as I think Westminster is, into a bigger group, that could help to overcome their problem with people using services outwith their borough area.

Tim Baxter: Sexual health services is an area that ACRA is going to have to continue to look carefully at.

Anna Soubry: You will find also that Nottingham’s director of public health is also now the director of public health for the shire-Nottinghamshire. I could completely concede that there will be people who would use city-based services, who live in the shire because of the ways our boundaries are drawn in Nottinghamshire. There may be other examples in the country, so we are not blind to it at all.

Q359Andy Sawford: Just on that, would the Director of Public Health have the flexibility to use the funding across those two local authority areas as they felt appropriate in terms of need? I would have thought that the local authorities themselves would resist that, particularly if they were a net loser.

Tim Baxter: They would need to look at, as they do in London, the flows of patients, and try to come up with a sensible agreement about recharging.

Q360John Stevenson: Minister, you quite rightly said at the beginning that the move of public health from the NHS to local government has been widely welcomed. At the centre of public health is going to be the health and wellbeing board. Like any organisation, where there are other organisations around, there will inevitably be some tensions. The danger for the health and wellbeing boards is that they become preoccupied with the commissioning services, rather than concentrating on their own issues of public health. How do you ensure that this does not happen?

Anna Soubry: I think through the way we have described the role of the director of public health. I have to say, with the varying compositions of the health and wellbeing boards across the country, one of the things that is coming out is the influence of CCGs and other medical professionals. They get public health. When you speak to a lot of GPs and other doctors, there is wide agreement that prevention is invariably better than cure, and the opportunity to do more preventative work at a local level is welcomed. Many of them are seeing the potential and the possibilities of doing that work. The structures are all there, as we have described, and I think the will is there as well.

Q361John Stevenson: Some health and wellbeing boards have expressed concern about the lack of ability to influence NHS commissioning boards locally. How would you respond to their concerns?

Tim Baxter: In the Health and Social Care Act, clinical commissioning groups have to consult the health and wellbeing boards on their commissioning plans, or if they are revising them. They also have to publish the opinion of the health and wellbeing board, when they publish the commissioning plan. There is also recourse to the commissioning board if they feel that their opinions have not been taken account of. There is not a veto, which I know that some people wanted, but there is strong influence.

Q362John Stevenson: Do you think that is strong enough influence?

Tim Baxter: Of course.

Q363John Stevenson: Turning to the Baroness, the present Government is a very strong supporter of localism and local government. We want to see strong local leadership but also accountability. On the CCGs, there is now going to be a restriction that local councillors cannot be on those boards. Why is that a good thing?

Baroness Hanham: I do not know, because I am afraid that I did not realise that they could not be on the boards. They are certainly going to be on the health and wellbeing boards, and are entitled to be on those. With the commissioning, I am going to have to pass on this because I did not know that they could not be on the boards.

Anna Soubry: It was to remove the political influence in what should be clinical decisions.

Q364John Stevenson: Do you not think you are taking away local political, electedbythepeople, involvement?

Anna Soubry: No, because of the health and wellbeing boards. They will be the overseers, the checks and the democratic process. I do not have any problem at all with the fact that local councillors should not be able to sit on CCGs.

Q365John Stevenson: So you are completely happy with that?

Anna Soubry: Absolutely. To have party politics or just politics involved in CCGs would be a bad idea. The checks and balances are there in the health and wellbeing boards and the national NHS commissioning board. You have all the other organisations and all those other structures to make sure that the CCGs are doing what they should be doing, but the accountability is through the health and wellbeing boards. Of course, there are still the overview and scrutiny committees; they will continue to play a very important role.

Q366Chair: But John’s point is right, surely? It is about accountability. You only have true accountability if you are elected by people to exercise it. The checks and balances within the system are the health and wellbeing boards within the remit of the local authority and the scrutiny committees of the local authority, but what happens if the clinical commissioning groups just decide to ignore them?

Anna Soubry: They cannot just decide to ignore.

Q367Chair: They can, can they not? What happens if they do?

Tim Baxter: The commissioning board can take action on that.

Q368Chair: The commissioning board can take action by doing what?

Tim Baxter: We ought to give you a note on that. Rather than misremembering something, I would like to give you a detailed note.

Q369Chair: It would be helpful to know what they can do and how their doing it would be triggered.

Tim Baxter: Effectively the commissioning board looks at the performance of clinical commissioning groups, and they can earn extra money through effective performance. If they are ignoring the views of their health and wellbeing board, they are certainly not going to get that.

Q370Chair: It would be helpful to know what they are going to do and in what way it is going to be triggered.

Tim Baxter: We will give you a detailed note on that, absolutely.

Q371John Stevenson: You are potentially taking it away from local government.

Anna Soubry: Do you mean commissioning?

John Stevenson: No, their inability to be on that board. The only sanction that you are appearing to suggest is through the commissioning board. It is not through the local elected officials.

Anna Soubry: The CCGs are deciding how to deliver the health service to people, and one of the whole thrusts of the Act was to take out the politics that is in too much of the health service. Instead of having decisions being based on sound clinical judgement, it was often being based on political opportunism.

Q372John Stevenson: You are also putting a large chunk of health back into local government.

Anna Soubry: That is public health. CCGs are commissioning services. While I accept that some of the role of local authorities will be to commission some services, it is not on the scale and not on the nature of CCGs. It is just a really bad idea to have councillors involved in those sorts of decisions, because I believe those decisions should be taken by health professions and the clinicians.

Q373John Stevenson: I am surprised that you do not have, at least, some form of local representation.

Anna Soubry: But why would you need a councillor to tell a doctor which particular pathway or service they should buy for their people? I take the view that the clinicians are the people to make those decisions, not councillors.

Tim Baxter: The joint strategic needs assessment and the joint health and wellbeing strategy will be delivered through the health and wellbeing board. That has a minimum of one councillor, but generally there are more elected members, so there is a mechanism for proper democratic accountability.

Q374Chair: Is there is a role for councillors in preventing ill health but not for curing it?

Baroness Hanham: I think that is probably correct, actually.

Anna Soubry: I think that is right. I absolutely do agree with you on that. You are talking about deciding, for example, where you are going to get your physiotherapy from. I am sorry, but I think the people who are more able to decide whether to get it from this provider or that provider, who know the quality of service, the value for the money and all the other things, are clinicians, frankly, not politicians.

Tim Baxter: The detailed commissioning work will be led by the director of public health, who will be a specialist public health person in line with the JSNA and the joint health and wellbeing strategy, but I do not think he or she will be particularly expecting elected members to take very close interest in the very detailed commissioning arrangements but more about being accountable for how you are actually going to have an impact on the population.

Anna Soubry: An example would be that some people might say that you should not be commissioning services for people with HIV because they have a particular view about HIV sufferers. The politics then become terribly involved and muddied in decisions that should be clinical and not political.

Q375Chair: That approach does not show the highest regard for local councillors, but never mind. Looking at services for the elderly, local authorities are commissioning those. Are you saying that they should be involved in that but once that elderly person becomes ill and is in hospital, the local authority does not have a role anymore?

Baroness Hanham: I do not think that the CCGs will be commissioning anything other than the hospital services, the x-rays, and the physiotherapy. The CCGs will do that. Local authorities instead are commissioning elderly care in homes-their own services’ community support. They are different. Having said that I had not appreciated that local people were not on the CCG, I do think it is right that they should not be. This is because they are commissioning how many beds and how many services they are going to need in the in the hospital, spending on drugs and things-that is all clinical.

Q376John Stevenson: A councillor can end up on the board of the hospital.

Anna Soubry: They do not make clinical decisions as a member of the board.

Baroness Hanham: That is correct. They do not.

Anna Soubry: They do not decide which procedures will be used within the hospital.

Q377John Stevenson: I accept that, but they are still involved in the decisionmaking of the hospital.

Anna Soubry: Yes, but not clinical decisions. Forgive me, but I do think there is quite a difference.

Q378Chair: For some of the services around sexual health-which are now part of the public health remit and come under the health and wellbeing boards-there are surely clinical decisions there. You do not expect an individual councillor to be involved in prescribing for a particular patient but the overall service delivery is a public accountability, is it not, which you are denying in other aspects of the health service?

Anna Soubry: Public accountability is through the health and wellbeing boards. Clinical decisions on what treatments to provide should be made by the health professionals.

Q379Simon Danczuk: Ministers, you can talk as much as you like about the dangers of not washing your hands, eating too many kebabs, drinking too many glasses of Chardonnay perhaps, or sitting too long on the couch.

Chair: Who are you looking at?

Simon Danczuk: I am not looking at anyone in particular. But is it not the case that recent research suggests that the best way of improving life expectancy is getting people back into work? What are your Departments doing to help local authorities develop employment schemes?

Baroness Hanham: The DCLG is doing this all the time. We are part of the thrust. We all know that one of the biggest things that we need to do is to get employment up and to ensure that people do have jobs because that is one of the things that gives them the best route in life. That is not just local government; it has got to be across the piece. We are dealing with the DWP and the job sector. The whole question of employment is a wider government issue. I accept what you say: that a person’s lifestyle might lead them to not be very employable. Again, that is about education, social services and what the benefits are. It goes much wider than just public health.

Q380Simon Danczuk: To summarise the question, the best way of increasing life expectancy-according to this quite extensive piece of research that has been done-is to get people into employment and increase their wage levels. That is the best way of doing it. Even from a public health perspective, why not devolve more responsibility and power to local authorities to improve and increase employment in their locality instead of doing it from up on high, through Work programmes?

Baroness Hanham: I think they already have. They already take that responsibility.

Q381Simon Danczuk: Do they?

Baroness Hanham: Local authorities are supporting apprenticeship schemes and looking after people who are not well, and encouraging them back. There is a role for local authorities but I do not think that there is a determined responsibility that they should be the only people involved in getting people back into employment.

Anna Soubry: I have to say that I am very surprised that the best way to improve our mortality rates is to get people into work. My understanding is that the best way to make sure that people live longer, happier and healthier lives is if we reduce our smoking levels, cut back on the alcohol and improve our diets.

Q382Simon Danczuk: I am referring to a study that was published in the British Medical Journal: "Decreases in unemployment and increases in average income in an area explained, to a large extent, why some local authorities ‘performed’ better that others", in terms of life expectancy.

Anna Soubry: I am not decrying that it is important for people to work, but I think some of those socalled lifestyle choices are the bigger determinants.

Q383Simon Danczuk: Looking forward 10 years, how will you measure whether the changes that you introduced on 1 April this year have been a success? How will you know?

Baroness Hanham: From the local government point of view, it is going to be from the director of public health. It is going to be the Director’s responsibility to check the figures, get the figures and know now what his limitations are and then, within 10 years, you ought to be able, on a data basis, to work out whether or not things are improving. It is just a matter of benchmarking where you are and then looking forward.

Q384Simon Danczuk: How will you know, Baroness? Never mind the individual directors of public health; how will you measure your success in terms of introducing this?

Baroness Hanham: The Department will measure success on the basis of the figures that will be presented, and will show and demonstrate whether this has actually been effective or not in terms of all of the things that we have been talking about today: the campaigns, the education and the director of public health’s role within the community. That should be easily demonstrated.

Anna Soubry: I agree. I would only add this. The test to me will be whether it is on the leaflets of people campaigning in the equivalent of the May elections, when councillors can proudly say what they have achieved on behalf of the people whom they want to serve or do serve, and their opponents will say, "These outcomes are not good enough and we will make them an awful lot better. Here is a similar authority under a particular political leadership and that is what they are achieving." When that happens, we will know that it has actually begun to work, in addition to everything the Baroness was saying.

Q385Simon Danczuk: Tim, have you got any more systematic ways of measuring it, rather than just political leaflets?

Tim Baxter: The public health outcomes framework, which has an overall vision of improving and protecting the nation’s health and wellbeing, and improving the health of the poorest fastest. That has two outcomes around increasing life expectancy and reducing the differences in healthy life expectancy and life expectancy between communities. It is focused on whether we can see people living longer and better, and there being lower health inequalities. That would be two ways of approaching it.

The framework has 66 indicators, which are very wide-ranging. It includes things like reoffending rates, school readiness, smoking prevalence, vaccination rates, and premature mortality. The Security of State for Health has made it clear that he sees that the UK-or England, which is of particular interest to him-in relation to other countries, in terms of preventable mortality, is relatively poor. In 10 years’ time, we would want to see that position having changed quite significantly.

The point that the Minister has made about leaflets is important. Duncan Selbie has this mantra that in a number of years-I forget the exact number-it will seem unimaginable that we would do anything differently. So in 10 years’ time, we will think, "Great, local authorities do public health. They lead on public health. They do all sorts of things and they do not do it in the way that the NHS used to do them. They do it in different ways, imaginative ways and they get better outcomes." That is what we want to see in 10 years.

Chair: Thank you very much, Mr Baxter and Ministers, for coming along this afternoon.

Prepared 1st February 2013