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CORRECTED TRA N SCRIPT OF ORAL EVIDENCE
To be published as HC 1048-ii
House of COMMONS
TAKEN BEFORE the
Tuesday 7 June 2011
Professor David Heymann CBE, Baroness Doreen Massey, Professor Brian Ferguson and David Meechan
Councillor David Rogers OBE, Jo Webber, Dr Frank Atherton and Dr Keith Reid
Evidence heard in Public Questions 70 - 175
USE OF THE TRANSCRIPT
This is a corrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
Taken before the Health Committee
on Tuesday 7 June 2011
Mr Stephen Dorrell (Chair)
Grahame M. Morris
Examination of Witnesses
Witnesses: Professor David Heymann CBE, Chair of the Board, Health Protection Agency, Baroness Doreen Massey, Chair of the Board, National Treatment Agency for Substance Misuse, Professor Brian Ferguson, National Transition Director for Public Health Observatories, and David Meechan, Executive Committee member, UK Association of Cancer Registries, gave evidence.
Q70 Chair: Ladies and gentlemen, thank you very much for coming. Could I ask you briefly, please, to introduce yourselves and the organisations that you come from in order that we can get that into the record? Professor Heymann, perhaps you could start.
Professor Heymann: David Heymann, Chairman of the Health Protection Agency.
Baroness Massey: Doreen Massey, Chair of the National Treatment Agency for Substance Misuse.
Professor Ferguson: Brian Ferguson. I am here as the elected Chair of the Association of PHOs between 2006 and 2011 and National Transition Director for PHOs from April this year.
David Meechan: I am David Meechan, representing the UK Association of Cancer Registries.
Q71 Chair: Thank you. The place we would like to start, if we may, is this. The Government has proposed that the Health Protection Agency is abolished and goes into the Department, presumably as the core of Public Health England, and that each of your organisations becomes part of that newlyestablished section of the Department. To begin with, we would like to hear from each of you how your organisations react to the bare bones of that proposal and what you think are the key issues we ought to be looking at as a Committee in considering the impact of that proposal. Perhaps we can start with Professor Heymann.
Professor Heymann: Thank you very much for giving me the opportunity to speak with the Committee. The Health Protection Agency board supports the commitment to public health, improving public health and reducing inequalities. It also supports the principles of the public health strategy and the move to Public Health England. We do this, however, understanding there are certain risks and that those risks involve independence of information, to maintain independence of the evidence necessary to form policies, and maintaining the specialist expertise within the Health Protection Agency at present.
Baroness Massey: We also, obviously, support public health. Drugs is not just about health issues. It is about a whole range of issues, impinging on crime, communities, families, employment, housing and so on. The reason that we are so supportive of Public Health England is because we have built up, over the years, some really good models of public health in that we have worked across Government Departments and, at local level, our regional managers have worked across a whole range of stakeholders, from housing, education, health, families and so on. Public health has always done this and been keen to promote positive community and individual health.
We have also focused on user involvement, equalities, family and community wellbeing and communications to support the importance of public health as well as the robust collection of data to support and back up the outcomes that we have desired. We have evaluated models of care, done public opinion polls, stakeholder polls on substance misuse and appraised value for money on substance misuse. All of those are issues which one should be looking at in relation to a broader spectrum of public health. The one thing I regret about public health-you have said in your introduction that it is neglected, and I agree-is that in this country we don’t do, in my view, enough research into public health issues. We do lots of superb medical research but we rely on the States and other countries for our public health research. In the grand scheme of things, I would want to see more of that.
Q72 Chair: Are you clear how the work of the National Treatment Agency will be carried on in the context of Public Health England? Will there be changes in the way you relate to commissioners who are responsible for commissioning the service that is delivered?
Baroness Massey: If you look at the Drugs Strategy in the public health White Paper, we see that most drugs and alcohol services are commissioned by local authorities through directors of public health, as you know, supported by Health and Wellbeing Boards-or will be. What we are looking to is a continuity of good commissioning. There is good commissioning about and local authorities will inherit the commissioning responsibilities of drug and alcohol partnerships, which, as you also will know as MPs, contain people from local communities. We would expect those arrangements to be carried on within any new arrangements. We do not anticipate GP consortia necessarily playing a direct role in commissioning for drug and alcohol services, but, of course, they will have an indirect role through their general care.
Q73 Chair: My question was more precisely related to the work of the NTA as it is currently carried on. Do you envisage that work being carried on, in effect, unchanged in Public Health England or do you think Public Health England will change the way that role is delivered?
Baroness Massey: It could do, depending on issues of, for example, the funding of local authorities and how that will impinge on the NTA’s work: who will pay for what? The same applies to the prison services: who will pay for what? It will be important to examine the funding streams and see how they are working out. In general, I hope the principles of what we are now doing would carry on.
One of our worries is that if local authorities have total responsibility for drug treatment budgets, then they may get somewhat neglected. Drug users are sometimes seen as miscreants and not worthy of spending money on. That has been defended, of course, by having a pooled treatment budget, which has worked at a local level. I would hope that would continue. Apart from the funding issues, the services are-
Q74 Chair: Has there been any proposal to change those pooled budget arrangements at a local level?
Baroness Massey: We understand that the Department will be funding the local authorities but I note that, at the moment, they don’t fund alcohol. I would hope that alcohol and drugs would be given some priority at a local level by local authorities and that the money would not go from drugs and alcohol to serve other very welldeserving things like schools, hospitals and so on. But I think there is a danger in the funding issue which we are aware of and very concerned about.
Q75 Chair: I don’t want to monopolise it so could we move to Professor Ferguson?
Professor Ferguson: Good morning and thank you for the opportunity to be here. The nine observatories in England produce a range of health intelligence tools for local organisations as well as outputs in support of national public health priority areas. It is important to say we also support NHS commissioning with a range of health intelligence tools.
All the observatory directors would very much welcome the opportunity for PHO functions to be seen as central to the work of Public Health England. I would particularly welcome the opportunity that brings to have greater integration of health intelligence, both across health intelligence organisations, such as the PHOs and the registries, but also integration between NHS commissioning intelligence and public health.
I would like to highlight a couple of risks as well as those opportunities. The PHO outputs and advice over the last 11 years or so are widely viewed as credible, authoritative and independent and we feel that consideration will have to be given to how that independence will be assured in the new health intelligence system within Public Health England. Finally, it is worth reinforcing the point about the work that we do supporting a range of local commissioners-not just Public Health England-and, indeed, I would hope, the NHS Commissioning Board as well. In the new system we have to make sure that scarce health intelligence skills-and those skills and expertise are scarce-have to be organised in an efficient way that integrates intelligence across commissioning and public health.
David Meechan: The Cancer Registries have two main functions. The first is to collect and collate information about every patient diagnosed with cancer and to submit that information to the Office for National Statistics for the publication of statistics on cancer incidence and survival. The second function is to analyse and interpret cancer data to support both the public health functions-such as surveillance and health needs assessment-and the planning and monitoring of cancer services, both at local and national level.
Some of the key issues within Public Health England are how Cancer Registries will relate to the NHS as well as to the public health community, whether that is within Public Health England or local directors of public health and Health and Wellbeing Boards. Then there is the need to maintain the links both with provider hospitals for the receipt of data about patients with cancer and also in terms of supporting local stakeholders, if you like, whether that is local clinicians through supporting clinical audit or the planning, commissioning and monitoring of cancer services, both locally and nationally. We work quite closely with the National Cancer Intelligence Network and I know that the National Clinical Director for Cancer, Professor Sir Mike Richards, is very keen that the valuable data generated from Cancer Registries is able to continue to be provided. Clearly, there are opportunities within Public Health England, as Brian said, to continue to work closely with Public Health Observatories, as we already do, and also to continue to work with the cancer screening and quality assurance centres.
As to the other threat, I would echo what Brian said about the risk of losing scarce skills, particularly during the transition period while there is uncertainty about the future structures of Public Health England and the processes for moving from where we are now into that new structure.
Chair: It is the new structure that Mr Tredinnick would like to ask you some questions about.
Q76 David Tredinnick: Can you explain why the Health Protection Agency would prefer Public Health England to be an executive agency rather than part of the Department, please?
Professor Heymann: The Health Protection Agency, at present, deals with various issues, including infectious diseases, environmental hazards and the safety and efficacy of biological medicines. These are important for the public health of the country. What is also important is that the evidence which comes from what the Health Protection Agency does is the best possible evidence with the best possible science behind it-science that can then be used to develop policies within the Department of Health. We feel that, as an executive agency, the Health Protection Agency and the other public health functions of England could be protected from any type of nonindependence of its evidence.
At the same time, the Health Protection Agency conducts research that is at the cutting edge of public health. This research is funded by various bodies such as the MRC and the Wellcome Trust-funding that comes into the Health Protection Agency to do this research-which might not be accommodated within the Department of Health. If that should be the case, and this research were stopped, the excellence that is within Public Health England would possibly gradually disappear into university and academic environments and the Government would lose some of its best scientists.
Q77 David Tredinnick: Thank you. Health Protection Units are a key part of the Health Protection Agency. Can you explain what they do and how satisfactory you think they are, please?
Professor Heymann: The Health Protection Units are the transcription of what is decided at the central level into action at the peripheral level by serving as guidance to the public health activities at the local level. Whatever is designated a national policy can be implemented through the HPUs which provide advice to the public health activities at the local level.
Q78 David Tredinnick: You are happy, therefore, that this will all sit comfortably under the new proposals.
Professor Heymann: Yes. As long as the risks that we have identified as a board are addressed, Public Health England seems to be the solution because it will bring together the epidemiology and technical skills of the Health Protection Agency, which would be moved there, with other activities within the Department of Health at present. This would make a more complete response to issues such as sexuallytransmitted diseases or others.
Q79 David Tredinnick: Do you not think there might be a need for local health protection committees? The Health Protection Agency and the Association of Directors of Public Health have both proposed that there might be a need for that. Do you think that-
Professor Heymann: I am sorry, would you repeat that?
David Tredinnick: Do you think there might be a need for local health protection committees? This is something that the Health Protection Agency and the Association of Directors of Public Health have both proposed. That is my last question.
Professor Heymann: A mechanism that effectively links PHE to local communities and supports local community engagement is clearly essential. Local health protection committees could be one of those mechanisms bringing together directors of public health and local PHE units and ensuring that working relationships are clear-provided that agreements to priorities and to share important information have been established. It is important to remember that committees can’t manage emergencies and incidents but that the responsibility must sit with the local PHE director.
Q80 Grahame M. Morris: There are a number of questions I would like to pose to Professor Ferguson, but while we are dealing with the evidence on the Health Protection Agency, I will follow that line of questioning to Professor Heymann. I note, from your opening statement, the importance you place on maintaining the independence of the Health Protection Agency but could you elaborate a little on your response to the consultation and the written evidence that you have given us here? You said that the planned changes "could create considerable risks to the national capability to launch multiagency responses to incidents and emergencies." I am thinking of things like a flu pandemic or, most recently, the E.coli outbreak we have seen in Germany. Could you give us your thoughts on what those risks are?
Professor Heymann: The Health Protection Agency has been designated as a category 1 responder under the Civil Contingencies Act. Its duties are to plan and prepare for risks, share information and to warn and inform the public about the risks. The Act also gives a duty to others to cooperate with the Health Protection Agency. Public Health England, we feel, needs to be designated as a category 1 responder as these mutual duties are an important part of ensuring the wider system is well prepared to respond to any incident.
Q81 Grahame M. Morris: Can I follow up on that? In those circumstances, who would take the lead both at the local and at the national level under the new arrangements?
Professor Heymann: Those are the arrangements which are being worked out at present. Our concern is that there be a coherent response from the central level all the way out to the peripheral level. I, myself, come from an agency in the US, which is a federal agency, which does not have authority over how states respond. It provides guidance and support. It is a very difficult issue, sometimes, to have states respond in the way that the federal government feels they should respond. The HPA has solved those issues and we hope that PHE will continue to solve those issues to make sure that there is a seamless response which follows national policies and national guidance.
Q82 Grahame M. Morris: At a local level, will a particular individual be identified as the lead in relation to a major incident or a health protection issue?
Professor Heymann: I believe those mechanisms are still being worked out. We are working with the Association of Directors of Public Health to make sure that the thinking is in line with what the Association is thinking as well.
Q83 Chair: Could we pursue this subject of the independent structure? Each of you has expressed concerns about the implications of this function being part of the Department rather than statutorily independent. I would like to hear views about that, in particular how such an agency, if it was established, would relate to the delivery of service at a local level of the kind Professor Heymann was touching on.
Professor Heymann: Would you repeat the first part of your question again?
Chair: Independence: should it be an agency or should it be part of the Department, basically?
Professor Heymann: If Public Health England is part of the Department of Health, and the Department of Health is making the policies for public health, the evidence will not be as clearly perceived and trusted as if it were coming from an agency which was not working within the Department of Health but working as an executive agency. It is very important that trust be maintained in scientific evidence and that that scientific evidence be obtained in the best way possible so there is no interference in providing that evidence to the policymakers.
Q84 Chair: What about in terms of the relationship with emergency service and delivery locally?
Professor Heymann: Our concern is that those be seamless from the centre through the commissioning and into the public health activities at the local level.
Q85 Chair: Does that not become more difficult if, at national level, it is independent in order to be an independent information-gatherer?
Professor Heymann: An executive agency would still be within the Government and this agency would respond in the way that the Secretary of State would request.
Q86 Valerie Vaz: Who do you relate to at the local level? Would it be the commissioners or your own outposts? How does that information filter down and back up again?
Professor Heymann: These are issues which are still being developed at present. We are hoping it can be developed in such a way that the Public Health Units will provide the guidance necessary for a seamless and responsive filtering.
Q87 Chair: Could we hear other witnesses on this point of the proposed structure?
Baroness Massey: This is a very interesting issue. I have worked for an arm’s length body, as they were called-the Health Education Authority-many years ago. There are tensions when you have an agency which is reporting to Government but is independent, in a sense. It often depends on very clear communication between the two to make sure that toes are not stepped on and things are consistently performed. In this case, as I understand it, Public Health England would be the agency, with all of the people that you have mentioned earlier in it, like the Health Protection Agency, ourselves and so on. That would require a good deal of working out. I don’t see why it shouldn’t work, provided that one did pay attention to the knockon effects at a local level-because there will be knockon effects. We know working locally is very important and that we need agencies which are not only at a national level. We would have to work out exactly how those local agencies operated and we would have to work out the commissioning and budgetary issues, but I don’t see that there would necessarily be any difficulty about that.
Professor Ferguson: I would very much echo the comments that Professor Heymann made about scientific credibility and how authoritative the PHO outputs and advice are seen to be. In the new system, that can be protected but it is a risk. Suddenly, outputs that may not fit with Government policy-for example, that give unpalatable messages about wider determinants of health-may not be seen as useful as perhaps they have been to date. The Observatories have had very much a quality assurance role around health intelligence as well and, with the right safeguards, that can continue into the new system.
In terms of local organisations, they look very much to the Observatories to help with comparative data-how their own organisations sit with others regionally or with clusters of their own organisations nationally. In my own PHO in Yorkshire and Humber, we are SHA-strategic health authority-employees, but it is fair to say that the SHA looks to us as very much an independent and credible source of advice on a whole range of health intelligence issues. At the moment, that feels possible within the current system. We need to make sure that that is safeguarded in the new system.
David Meechan: I would agree with that in terms of safeguarding the independence of the work and the output. The key thing for Cancer Registries would be the need to ensure that the relationship with NHS bodies, both locally and nationally, is able to continue-the mechanisms for enabling that to happen. Specifically, with cancer, we would need to ensure the continuation of the current NHS Act provision under which Cancer Registries are able to hold and process patientidentifiable data. That is potentially easier within the NHS, but I suppose there would be other ways around that.
The final point relates to the ability to generate income from other sources as well. The Cancer Registries, to a certain extent-not a great extent-do commissioned work on behalf of local cancer networks or research bodies. I am also the director of a Public Health Observatory and I know that Public Health Observatories have been successful in generating income from a range of sources. Again, potentially, that could still be done from within the Department of Health but I suppose it would be easier as an executive agency or special health adviser.
Q88 Valerie Vaz: Could you describe that process, the income generation?
David Meechan: Both the Cancer Registries and the Public Health Observatories do work for a range of different customers, if you like. On the cancer side, we do smalllevel commissioned work on behalf of cancer networks, for example, and we do work with local academics on research projects. The Public Health Observatories have also been commissioned. I am director of the East Midlands Public Health Observatory and we take the lead on renal health. We have been commissioned by NHS Kidney Care to do some work. It is that ability to add to the core funding which enables us to broaden our expertise.
Q89 Valerie Vaz: That is because you are seen as independent.
David Meechan: Yes.
Q90 Yvonne Fovargue: I would like to focus on the drug and alcohol services, if I may. What roles do you see the directors of Public Health, Health and Wellbeing Boards and the GP consortia playing in commissioning the local drug and alcohol services?
Baroness Massey: Our understanding is that Public Health England itself will not commission services but will have an important role in giving specialist advice to local authorities about planning drug and alcohol services, benchmarking performance of systems and disseminating best practice. I mentioned the national role earlier on and it is obviously important to achieve the Government’s ambition of transforming communities into drugfree places. I touched on the issue of budgets earlier and the tensions that there might be there. I also touched on the issue of there needing to be some sort of subnational level to handle issues of commissioning and also to engage staff and communities in change. Public health is about the health of communities and you have to involve them in that. In the interests of efficiency, we would want new structures-new arrangements-to map on to emerging structures, for example, the NHS Commissioning Board and the work of the Health Protection Units.
Q91 Yvonne Fovargue: How local a presence do you think Public Health England would need to have to fulfil the role effectively?
Baroness Massey: Very local. There is a lot to be said for collaboration between local authorities, particularly where the borders coincide. Drug users migrate from one place to another and the knockon effects on health in one area coming from drug problems can translate itself into another area very easily and quickly. Thus, I think this should be as local as is humanly possible.
We have a structure, currently, of regional managers who do work with drug and alcohol action teams at a very local level in communities. The drug and alcohol action teams have generally worked-where they have worked-very well indeed in that they have representatives from all the current and important agencies such as health, education and so on, at a very local level-local authority level. It needs to be as tight as that.
Q92 Yvonne Fovargue: Thank you. The National Treatment Agency has said that: "For the first time, funding streams for drug and alcohol treatment will be aligned in both community and criminal justice settings." How do you think this will work? What do you think will be the benefits and what do you see as being any issues for this?
Baroness Massey: First of all, as you know, prisons are incredibly complex and difficult places, especially in relation to mental health and drug and alcohol misuse. For prisoners we need to have, as people in the community do, a care pathway and a key worker. The Ministry of Justice Green Paper and Drugs Strategy have confirmed that prisonbased treatment will be funded entirely by the Department of Health and made available to local partnerships as part of the "One pot, one purpose" ethos. This means that local partnerships and, in due course, local authorities will be able to commission evidencebased treatment services that meet the assessed needs of prisoners in their particular areas.
The benefit of this will be a renewed emphasis on prisoners recovering from dependency and also stronger links with community services to ensure that dependent clients receive treatment and recovery when they leave custody. When someone leaves custody is a crucial time. They can easily fall back into substance misuse habits and they need to be grabbed then. I think that is the answer to that one. Is that all right?
Yvonne Fovargue: Yes. Thank you very much.
Q93 Chair: Am I missing something? It seems to me that the National Treatment Agency is an agency that is primarily responsible for supporting commissioners’ system delivery-care and support delivery-whereas the other three agencies we have on the panel this morning are more concerned with the dispassionate collection of scientific evidence. I don’t really understand why the NTA is lumped together with the other three witnesses we have this morning. It seems to me that you are doing something completely different.
Baroness Massey: You are absolutely right. We are very different. We deal with delivery of services to communities via a regional mapping. We have done-I wouldn’t call it research-surveys, but we are principally, as I said earlier, working with a range of organisations at national and local level to deliver good drug services, to encourage people to emerge-
Q94 Chair: In the discussion we were having about the independence of Public Health England, the case that Professor Heymann was making was that this is evidence collection that should be independent because it is factual and science based. Of course, your services are factual and science based as well, but it is a different concept, isn’t it?
Baroness Massey: Yes. This is a more clinical approach, whereas we are, if I could use the expression, a more communitybased approach, based on service, public opinion and on stakeholders. This is not hard research such as David is talking about.
Professor Ferguson: There is one area where there is a much closer connect between the NTA and the rest of the agencies, and that is in the National Drug Treatment Monitoring System.
Baroness Massey: Yes.
Professor Ferguson: The data is collected, analysed and intelligence produced, in many cases by the Observatories. The NDTMS function is provided in six of the nine Observatories around the country.
Q95 Chair: But that is an Observatory function rather than a service design function.
Professor Ferguson: It is. That is correct. The money comes to the NTA and then the service is essentially commissioned from the Observatories.
Baroness Massey: We can follow trends in this way and every local authority has a trend.
Q96 Chair: Both are necessary. Don’t misunderstand me. It just seems to me they are different in nature.
Baroness Massey: They are different.
Q97 Grahame M. Morris: Chairman, if I may move on to some issues around the Public Health Observatories, I would like to ask Professor Ferguson for his view on the Minister’s response to an adjournment debate that was held on 17 May, initiated by myself. The Public Health Minister, the Member for Guildford, told the House that "the core public health information and intelligence budget remains similar to previous years" and, with additional grants, "overall funding will be about the same." How accurate is that statement, in your view? I am sure the Minister would not deliberately mislead the House.
Professor Ferguson: I would make four points, factually, about the figures. The first is that PHOs were told, in a letter on 18 February from the Deputy Chief Medical Officer, of a 30% budget cut to funding levels in 201112. The precise wording of that letter was that financial plans of the Observatories should be based on an allocation of 70% of 201011 funding levels. That is consistent with what the Minister said in the House about a cut to the core functions of Observatories.
The second point is that in 201112 the PHOs’ core budgets were reduced from £5.1 million to £3.9 million. The total figure that we think has been allocated to the Public Health Observatories from the Department of Health in 201112 is just over £8 million. The £12 million figure that was quoted in the House is not a figure I recognise but, then again, it didn’t relate to any particular time period. Indeed, it didn’t say what it did and didn’t cover. Therefore, I can’t reconcile to the £12 million but that may be because I don’t know what is in the £12 million.
Q98 Grahame M. Morris: In terms of that £12 million, when your colleague mentioned being involved with a particular Observatory that was doing some work commissioned through the renal service, is that that kind of direct grant?
Professor Ferguson: Yes. What is in the £8 million is the core allocation to PHOs, which, as I say, is about £3.9 million. There are then allocations to some of the specialist Observatories, and that is in areas such as child health and obesity. Then there are some specific projects, such as health profiles. There are small sums of money in there. In the case of David’s Observatory for renal there is about £25,000 in those figures. All of those add up to about £8 million. If you add in the National Drug Treatment Monitoring System figures, then you get to just under £10 million, but, as I say, that is funding through another source.
I would make one final point about the funding. The really important issue for this Committee about the funding is not that there has been a cut in funding-everyone else in the NHS and elsewhere is taking funding cuts-but the significant loss of capacity that has already occurred across the PHO network, which is roughly 20% in the last 12 months. Those are hard figures. On the current trajectory, that will worsen during this financial year if action isn’t taken to stabilise the Observatories.
Q99 Grahame M. Morris: Can I follow up on that? I am grateful for that response. It is very illuminating. I note, Professor Ferguson-and you have already stated, for the record, that you were previously Chair of the Association of Public Health Observatories which had all of its funding withdrawn by the Government last year, so I understand, and no longer exists-that, as part of the drive to efficiency, you acknowledge in your written evidence that Public Health Observatories need "to show efficiencies". However, you are "acutely aware of the need to retain critical expertise," which you have just mentioned, during this transition period. You specifically ask for a "firm commitment to funding until Public Health England goes live"-so there is no hiatus-"with no further cuts during" the current financial year. Can you, for the record, and for the information of the Committee, give some indication of what this "firm commitment" to funding would enable the Observatories to do?
Professor Ferguson: The firm commitment to funding, at least until Public Health England goes live, would allow us to stabilise the capacity loss that we have seen in the last year. If we continued in our current situation, about 40% of the remaining posts within Observatories are on fixedterm or temporary contracts and about 80% of these actually finish this year. What we have been told to date by the Department is that we cannot renew those contracts, and indeed those staff who have already left we cannot replace. My estimate, which I think is a conservative estimate, would be that we would lose between 40% and 45% of capacity by March 2012 on the current trajectory. That, in an area where health intelligence skills are very scarce, as we have already said, is a real risk to the establishment of a solid public health intelligence function within PHE.
On the APHO issue, we have accepted in the Observatories that APHO has gone. The key issue for us is whether the new mechanism, whatever it is, is an efficient way of organising business across the nine Observatories in England. I would have to say, at the moment, that the coordination of those activities and indeed the managing of our relationships with other key stakeholders, such as NICE and the Information Centre-our marketing profile, our communications-is a lot more difficult than it was a few months ago. Coordination of those activities, as you might expect me to argue, was very efficiently undertaken under APHO.
Q100 Grahame M. Morris: Very briefly, to follow on from that point-indeed, Baroness Massey raised in her opening remarks about not having enough public health intelligence and relying upon academic studies that are carried out in the States, in particular-we are losing 20% capacity this year. But if we lost 40% to 45% capacity, given some of the big stories that are in the news at the moment about the reemergence of TB in inner city areas, issues around MRSAresistant strains that are in cattle and the risks to public health through transmission into milk, and obviously E.coli, and with the Olympics coming up and hundreds of thousands of people coming here in July next year, do you think this is a substantial risk that we should identify clearly to the public and to the Department?
Professor Ferguson: I personally do. One area I haven’t touched on is the one that you have mentioned, which is the links to the academic sector. I would say-
Q101 Grahame M. Morris: And the opportunity cost if we have to buy in that expertise which already exists and is very cost effective.
Professor Ferguson: Indeed. In areas like child and maternal health, obesity and elsewhere, we have very wellestablished links with academics. As I said in the written evidence, we have been part of the Department of Healthfunded Public Health Research Consortium across the Observatories since it started in 2004, I think it was. Those links are very much valued by the academic community.
Q102 Valerie Vaz: As a followup to that, where is that expertise going?
Professor Ferguson: From the Observatories?
Valerie Vaz: Yes.
Professor Ferguson: We did an analysis of that in January or February when we had lost about 10%. Some of it has been lost to the system completely and, as always happens in transitions, some people take the opportunity to go. Some have gone to the commercial sector. One or two people have gone back into training, and sometimes public health training, which is good, in the sense that it is not lost to the system completely. That was the analysis we did then. We would like to do an analysis of more uptodate figures because what we calculated in terms of that 20% figure was that 75% was made up of public health consultants or specialists and information analysts. That, for me, is a real worry because it is the bedrock of what Observatories do, and we are losing people like that now.
Q103 Valerie Vaz: You have the grand title of National Transition Director. Could you explain what that role is?
Professor Ferguson: I have a couple of things to say. I was asked to take on that role from April by the Deputy CMO and by the transition managing director for Public Health England. The essence of the role is twofold. One is to help define the future state of the intelligence function within Public Health England, and that is working with a range of agencies such as my colleagues that are here today from the other intelligence parts of the system. Thus, one function is about designing the future state.
The other function is to make sure that Observatory functions transition smoothly into Public Health England. That is where, of course, the concerns about capacity come from. As Mr Morris said, in the written evidence, we have been working, over the last year or so-or probably more than that-towards developing a single work programme across all the Observatories for national pieces of work. That, again, is a very efficient way of doing things. But we would be the first to say, in the Observatories, that there is more we can do to be more efficient and we are working hard at doing that.
Q104 Valerie Vaz: Finally, what is happening to the group that is chaired by Professor John Newton, the Information and Intelligence Group? What is happening to that?
Professor Ferguson: That group is meeting as we speak. In fact, it meets tomorrow. The role of the working group is threefold. It very much mirrors the role I described for myself in relation to the Observatories. It is there to design the future state of the intelligence function within Public Health England; it is there to oversee existing intelligence functions and, where appropriate, to make sure that the workforce associated with those functions goes into Public Health England; and the third and final role of the group is to ensure that essential functions are protected during 201112 as we go through transition.
Q105 David Tredinnick: We heard evidence previously about Public Health Observatories. I got the impression that it was a first-class organisation with PHOs in different regions taking national responsibility for particular aspects of health or particular disease areas and that it all worked extremely well.
My colleagues have asked you lots of questions about the transition, but are you confident that, when we have gone through the transition and there have been these funding changes and you have had these losses of employees-some going into training and some retiring-that you are going to have a system that is at least as good as the one that went before it, please?
Professor Ferguson: In response to the first observation you made, I would argue, as you said, that we have had a very efficient network in terms of taking leadarea expertise. Indeed, as I am sure David would recognise, the Cancer Registries and others have very much followed that model in terms of how UKACR operates. The leadarea model has been very successful.
In terms of my confidence about where we are going, the honest answer is I am not sure because we have, currently, a loss of capacity along the lines I have described, with the trajectory for us to lose more people. As we speak, the University of Durham is meeting with the NorthEast Public Health Observatory director. That meeting is with the executive committee of the university to decide whether to make the staff of the NorthEast PHO redundant- at least the university-employed staff. Who knows what the outcome of that will be? There is not a lot of optimism out there among the PHO directors that we will be able to stabilise capacity at the moment. That situation can be rescued very, very quickly.
Coming back to the question that was asked earlier about the commitment in the House to the level of funding being at roughly the same level as before, it would be very interesting for us to know how we access that additional funding, which I think was described as coming through Department of Health additional grants and so on. If in fact what has been planned is an additional sum of money that would allow us to not have a 30% cut in 201112, then clearly we would be interested in knowing how to access that.
David Meechan: If I can follow up on that comment, both on behalf of the Cancer Registries as well as in terms of my role with a Public Health Observatory, there are two issues as well as the funding issue. One is the general uncertainty of the staff within the organisations, not knowing (a) whether they have a job, (b) where that job might be and, (c), who their employer will be. The sooner that uncertainty is resolved, it will remove a significant risk. That obviously depends on getting clarity as soon as possible on the future functions and structure of Public Health England.
Q106 David Tredinnick: There is a degree of fog out there at the moment: uncertainty, people are leaving the organisation and, as we have already heard in previous evidence sessions, there is not enough data about health issues in the country on which to make objective decisions. Professor Ferguson, you have said that you are not quite sure how it is going to work out-and you are in charge of transition. Going back to my original question: do you think we can have confidence that, at the end of this road, we are going to have a data collection system through the new mechanism that is as good as the old mechanism, please?
Professor Ferguson: For me, it is early days for the I&I working group that the question was asked about earlier. A lot of good work has brought together the different agencies involved, but I think everybody in the group would probably say it is early days. The real test will be in a few months’ time when we really are looking at the design stage of the new system. There have to be very demonstrable efficiencies as we organise health intelligence better across the agencies-the Registries, Observatories and so on. Once that is done, we have to be in a position where the intelligence that is provided is done using economies of scale at subnational level, at national level and so on. We are simply not there yet, but that is the design work that has to take place in that group. It feels like early days.
Q107 David Tredinnick: You need to design a better framework to get the better results. Is that right?
Professor Ferguson: Yes.
Q108 Chair: It would be a correct inference, wouldn’t it, from the title that you hold-National Transition Director for Public Health Observatories-that the Government wishes to maintain a national system of Public Health Observatories?
Professor Ferguson: Indeed.
Q109 Chair: Is that a correct inference?
Professor Ferguson: I think it is, yes.
Q110 Chair: You think it is.
Professor Ferguson: It is.
Rosie Cooper: You hope.
Professor Ferguson: I hope, yes.
Q111 Rosie Cooper: Will you have the resources to be able to function?
Professor Ferguson: There are not the resources to enable us to coordinate the activities of the Observatories in the way that we did before because of the issues raised around APHO. Colleagues who sit in the Observatories will be aware that only in the last few weeks were we told there will probably be no coordination function across the Observatories from August or September time either because of the loss of APHO or within the Department. That is something we need to follow up with Department colleagues very urgently because I am concerned that if we don’t have the coordination function across the Observatories then we will continue to see a loss of capacity.
Q112 Grahame M. Morris: Can I come back on that, please? It is a really interesting point. Certainly, coming from the north east, I am very concerned about what is happening with our Public Health Observatory. It has done some excellent work in relation to direct commissions from the Department, dealing with health inequalities for people with learning disabilities as well as some excellent health inequality stuff-"Miserable Measures" and other reports it has been involved in producing. But I still can’t understand in my own mind why the PHOs are being treated differently to the cancer networks. In view of what is happening with threats to existing Observatories and loss of key staff, how can you be sure that, under the new arrangements, you won’t either be abolished or merged into something else?
Professor Ferguson: The honest and short answer is we can’t be assured of that. I perhaps should have said at the start that I am a codirector of a Cancer Registry in Northern and Yorkshire, as well as being director of Yorkshire and Humber PHO. It does, exactly as you say, feel very different. I sit in executive meetings at our Cancer Registry and we have taken a less than 1% hit on funding in 201112. We are carrying on largely "business as usual," although David, I am sure, would be the first to say there is a lot of national work to centralise and be more efficient in the registration function in the Registries, but it feels very much "business as usual". We talk about when we are interviewing, when we are recruiting to vacant posts, and it feels like a completely different world in the Observatories. I am sure all my colleagues in the Observatories around the country would echo that.
Q113 Rosie Cooper: It is a bit like currently knowing you have a PCT till 2013. It is like the Mary Celeste. You might call it that, but it doesn’t necessarily deliver anything like it did before. Therefore, I don’t take a great deal of comfort from the fact that you are still there with a lot less staff, possibly a lot less direction and you are not coordinating. Are we going to have a load of little silos with a few little people but it looks good?
Professor Ferguson: It is my job to make sure, working with other organisations on the I&I group, that we do as much as we can to mitigate against that eventuality. If the question is, "Am I confident that we will get there?", then, as I have already said, I hope that we will get there. The reality is that, on the current direction of travel, we will continue to lose people in this financial year.
Q114 David Tredinnick: Going back to cooperation and coordination, again when we had evidence before, one of the strongest aspects of the Observatories was that everybody knew what everybody else was doing. We had these specialist organisations and there was a feeling of confidence about them. There was almost a collegiate style of cooperation and management. Now you have told us that the cooperation and coordination aspect is one of the most serious issues, haven’t you, in the future?
Professor Ferguson: What I am saying is that, with the loss of the central funding we had before, the coordination function is much harder to perform. I can give you a couple of practical examples that might help. We have had very good relationships with a number of partner organisations, such as NICE and the Information Centre. I used to have top team meetings between APHO and the Information Centre, but those have gone because it is not my remit to do that anymore. We used to have a very strong conference presence at places like the NICE conference and the NHS Confederation. All of that has stopped. That means it is very difficult to disseminate the outputs that we previously had. We previously coordinated the production of a range of technical briefing and other reports across APHO. Those have stopped. The website is no longer actively managed. It is maintained but it is no longer developed. There is no proactive development work of the APHO website.
All these things may change. Certainly these are things that have been flagged within the I&I group and people recognise they need to be dealt with but, as of now, these are the sorts of examples of the coordination that has stopped.
Q115 Chair: I am sorry to be personal, but you are the National Transition Director. Are you not telling us something that should be done and does the buck not stop with you?
Professor Ferguson: The work that we are doing within the I&I group is exactly the work I am describing. Here we are in June. APHO stopped in March, which is why I said it is early days on the I&I group. The work that needs to be done to prepare the Observatories for the new system is exactly the work of the I&I group. I need to play a part in that and I am playing a part in that alongside colleagues from the other agencies. The problem is that the other agencies on that group are not facing the same scale of budget cut as the Observatories have faced and it feels a very different place in the Observatories.
Q116 Grahame M. Morris: If the DH were commissioning a study in order to compile an evidence base on a particular issue, what would the difference in cost be? Do you have any figures about the cost of using the inhouse service with the analytical expertise that the PHOs have compared to, say, KPMG or some international private health care consultancy?
Professor Ferguson: Our core funding is, as I said earlier, around £3.9 million-
Q117 Grahame M. Morris: It is small beer in the context of £103 billion, isn’t it?
Professor Ferguson: It is a small amount of money and we have generated, in response to the point David made earlier, in the order of another £11 million in 201011 on top of our core funding. I think we have demonstrated that we have been hugely successful across the Observatories in operating in a health intelligence market, which is what we have done in the last five years or so.
Q118 Rosie Cooper: I have some questions to address to Mr Meechan about the Cancer Registries in the future, but, before I do, I have a personal question that I have been thinking about. You hold 8.5 million cancer registry records linked to 34 million hospital records. Yet, last year, when I met cancer charities they all complained that you don’t collect information about staging. Is that (a) accurate; (b) where we are; (c) how did you get there and (d) isn’t that stupid?
David Meechan: Where shall I start? It is partly correct. The Registries do collect some information on the stage of disease-that is, how advanced a patient’s cancer is at the time of diagnosis. One of the key things that was picked up in the recent National Audit Office report and Public Accounts Committee and, indeed, is a key part of the cancer outcomes strategy, is the challenge for all Cancer Registries to get to the level of the best Cancer Registry in terms of having at least 70% of cases with stage recorded.
Q119 Rosie Cooper: Why would you not record them all? It is the very thing that defines treatment. The whole thing is just nonsense.
David Meechan: There are reasons, which I haven’t got time to go into now, as to why 100% isn’t an appropriate target. The reasons it has not happened so far are several, but one key one is that the Registries are reliant on receiving that appropriate information from provider hospitals and that information hasn’t been flowing as well as it should have done.
Q120 Rosie Cooper: What could you have done to make it flow? To me, this is the core of where the whole treatment thing starts. It bewildered me then and it baffles me even more now.
David Meechan: You are correct that it is a key component of the data that we should be collecting. What is happening now is, first of all, the NHS framework requires hospitals to provide that information to Cancer Registries. It is also part of the standard contract between PCTs and hospitals that they should provide that information to Cancer Registries. What we are also doing within the Registries is adopting a common national system. In effect, we are developing a single national cancer registration system using a common computer system, common approaches, if you like-common processes-and the target is that all Registries will be at that 70% level by the end of 2012.
Q121 Chair: I am still struggling with this idea that there are 30% of people who have had a diagnosed case of cancer where we don’t need to know what stage the disease has got to.
David Meechan: There are certain cancers for which it is not really appropriate. The best Registries at the moment achieve that 70% and, building on that expertise, the aim is to get them all to that level of 70%. If I give you another example, that might help. There is a small of number of cases for which the only thing we know about the patient is that this patient had mention of cancer on their death certificate. That patient was never diagnosed in a hospital as such, so it is not appropriate for it to be staged in that instance. There are several-
Q122 Chair: Our prime focus should be living patients, shouldn’t it?
David Meechan: Yes.
Q123 Rosie Cooper: Perhaps you could let the Committee have some information on it.
David Meechan: We will do.
Q124 Rosie Cooper: Frankly, you have existed for this long and not got this absolutely crucial piece of information. "Bewildered" is a polite way of putting it. I wonder what, in God’s name, everyone has been doing. The doctor needs to know that information to treat. That will tell us whether cancer has been diagnosed late and that plays into all the decisions that follow thereafter. How anyone could say, "I’ve been involved in a registry and we haven’t actually got that information," I don’t know. Hospitals may not have given you that information, but you haven’t dealt with it via the Department of Health, or whatever, to ensure that you get it and are now just saying, "We’ll have 70% of it by 2012." I question what the heck is going on.
David Meechan: I agree entirely in terms of the need for it. Part of the issue is, as you quite rightly say, that the stage of cancer should be recorded at the multidisciplinary team meeting where the patient’s treatment is discussed. That happens most of the time. What doesn’t always happen, though, is that stage is recorded in an appropriate computer system or whatever.
Rosie Cooper: Perhaps you need Professor Heymann to give you a hand.
David Meechan: That is the first issue. The second issue-as well as it not necessarily being recorded within the hospital notes-is that that is not then routinely transmitted to Cancer Registries. That is what is being addressed at the moment.
Rosie Cooper: So that’s okay then.
Q125 David Tredinnick: Following on from Rosie, I find it very hard to take on board, with primary care trusts in position for so long, that we are now being told they are not providing the information that you require to make assessments. I understood that it was roughly three months a stage in cancer, as a rule of thumb. If you are not having information of anybody in stage 1 cancer, there must be some failure to provide treatment for those who develop cancer at a later stage.
David Meechan: There are two issues there. The first is, as I said earlier, that a stage is, by and large, discussed clinically in terms of informing the treatment of the patient. I would reassure you that that is the case. Then the issue is over the recording of that stage, whether it is put in the hospital systems, and then the transmission of that stage to the Cancer Registries. That is where the emphasis is, currently, to improve that flow of data. That is why, as I say, within the NHS operating framework this year it has been explicitly stated that NHS trusts are expected to provide that information to Cancer Registries. Secondly, it is why it is in the standard contract between PCTs and the trusts in terms of information flows.
Q126 Chair: I think we have covered that. What the Committee would like is a note as to this 30%: why is 70% acceptable? It sounds an extraordinarily low number to me.
On a slightly different point, the Cancer Registries carry out the same function for cancer patients as Public Health Observatories do for patients in generality. It is striking that both Professor Ferguson and Mr Meechan are, reciprocally, members of the other team at a local level. Do we need two separate processes here-two separate cultures, as Professor Ferguson was describing it?
David Meechan: You are absolutely correct that there are very close similarities and there is a lot of current joint working. There are joint directors, such as Professor Ferguson and myself, and there is close liaison between many Registries and Public Health Observatories. The one key difference between the two, as I think I said earlier on, is that Cancer Registries have two functions. One is the analysis, interpretation and intelligence function, if you like, which is the prime function of the Public Health Observatory as well. The other function that Cancer Registries have is the collation of data and the building up of a dataset about everybody who is diagnosed with cancer. That is the collation, the building and managing of a dataset which the Public Health Observatories do not have-a prime data collection or collation.
Q127 Chair: Is this individual patient notes, effectively?
David Meechan: Yes. It is generated from individual patient notes. I would agree entirely with the point that Brian made earlier, that we need to maintain and develop the closer integration of public health intelligence functions between Public Health Observatories and Cancer Registries, but also with other intelligence functions between the HPA and the NTA.
The other thing for Cancer Registries is the need to look both ways: to similar public health intelligence functions but also to the cancer community, if you like, and the need for the specialist functions of the registration, the data collection, the coding side of things, and also in terms of specific analyses, like cancer survival analysis, and to relate to things like the National Cancer Intelligence Network, which is a partnership of public and private bodies, including the major cancer charities. Again, as I said earlier, Professor Sir Mike Richards, the National Clinical Director for Cancer, is very reliant on the National Cancer Intelligence Network, of which Cancer Registries are partners, in terms of providing useful information to monitor the progress of the national cancer outcomes strategy, including the aim of saving 5,000 lives a year. That also requires the need for improved data on how early patients are being diagnosed. That is a critical factor.
Q128 Chair: Is there a reason why there is a Cancer Registry and not, for example, a diabetes registry or a heart disease registry?
David Meechan: That is a good question. You would have to go back in time to understand the origins. I suppose it is because cancer is a major killer. There are over a quarter of a million new cases of cancer diagnosed each year. It is a major disease in which there is a lot of interest.
Q129 Chair: The parallel with coronary heart disease would be pretty precise in that respect. Therefore, the answer to my question, "Is there a good reason?" is, "If there is, it is history."
David Meechan: Yes, probably. There is clearly the need for an equivalent intelligence around heart disease, but it is structured differently.
Q130 Rosie Cooper: May I continue where we were before. In essence, you have described difficulty in getting data to the level you want, but now there is an element of compulsion. How confident are you that Public Health England will be able to have systems in place to get that comprehensive, accurate and timely information which you require, especially if the NHS becomes fragmented-more diverse-with other providers coming in? You can’t do it with a tame bunch. How are you going to do it when we are out there with everybody having a go?
David Meechan: That is also a good question. In terms of the current situation, if I can reassure you again, the Cancer Registry is working with the National Cancer Intelligence Network and they are putting a lot of effort into providing more timely and complete data, including stage. With current systems, that is what we are doing and the aim is to achieve that target by the end of 2012.
The point you made was if there is more plurality of NHS providers, then that will make the system more complicated and we would have to make sure that there were appropriate mechanisms in place to ensure that that data flows. Therefore, we would need to make sure that the kinds of things which are currently in the NHS operating framework are built into the new system. Building it in through commissioning consortia-in their arrangements with provider trusts, there might be some contractual agreement that they would provide the necessary information to the Registry-is one way of doing it. At the moment we have the issue that, if a patient is solely treated in the private sector, we don’t necessarily know about that patient’s cancer. We do in some cases, but it is on a goodwill basis. There is no contractual-
Q131 Rosie Cooper: That is minimal, isn’t it? In the numbers, that would be minimal.
David Meechan: It is relatively small, but there is an increasing amount of private sector treatment. It will depend on whether a patient is diagnosed in the NHS sector, in which case we should know about them. You are correct that if there is more diversification of providers, we would need to make sure that, in the new system, those safeguards are built in.
Q132 Rosie Cooper: You couldn’t get all NHS providers to give it you and they are contracted to you. How confident are you that you can get on top of this and actually deliver?
David Meechan: I’m pretty confident that we will. As I say, we are moving towards a single system. We have appointed a single lead for cancer registration modernisation within England. We are being very closely monitored by the Department of Health and people like Professor Sir Mike Richards.
Q133 Rosie Cooper: How will it fit within Public Health England? That is what I am really saying. Are you sure they will have the resources and that this will all fit in as you have described?
David Meechan: Going back to an earlier point, although our financial allocation for this year has not yet been formally confirmed, our understanding is that the funding for 201112 for Cancer Registries will be similar to last year. The efficiencies will be through achieving more with the same rather than taking the kind of cuts that the Public Health Observatories have. The biggest risk, again, as I said earlier, is in the uncertainty. All we have been told so far is that the cancer registration functions-and indeed the same applies to Public Health Observatories-will be within Public Health England. What we don’t know yet is what those structures will be and that uncertainty is leading to the risk of losing skilled staff. That is the biggest single risk in terms of the resilience, if you like, of this moving forward into public health.
Rosie Cooper: In my world, a oneyear assurance is not very much assurance at all.
Q134 Chair: This session has come to a close, unless there is anyone on the witness panel who would like to make any closing comment or any observation that has been buzzing around.
Baroness Massey: Could I make one closing comment about monitoring? This has been a fascinating discussion that we have been having here. Could I send you some information about how the drug treatment monitoring system works because it did have a rocky start? Difficulties had to be overcome but were overcome. It was a rather complex process and I can send you details of that if you would be interested.
Chair: It would be useful. Thank you very much.
Professor Heymann: I would like to bring up two issues that were raised, again to underline the importance. One is the need for a seamless response-levers to pull when there is a pandemic and the assurance that what needs to be done will be done at the very local level. That includes the type of partnership that exists today between the directors of the Health Protection Units and the local authority directors of public health. They need to remain keen partners in this.
The second is to come back to the issue of expertise. HPA is also losing expertise. It is losing expertise because of the uncertainty in what will occur in the future. Some of the best people-two of the best people, in fact-have already left and gone to a university environment. It is very important that we ensure that decisions are made rapidly and that staff are reassured of what will be coming in the future.
Professor Ferguson: I have one word, the integration word, which I know I have used a few times. There is a role that I have to play and all the other agencies have to play in the designing of Public Health England, which is about making sure that what we end up with is a better integrated system of intelligence than the system we have now. Personally, I am absolutely committed to that, but, as everybody here today has said, we have to make sure that, as we move from where we are now to where we need to be, we protect the scarce skills and expertise that we have in the system.
Chair: Thank you very much. Thank you for your thought-provoking evidence.
Examination of Witnesses
Witnesses: Councillor David Rogers OBE, Chair of the Community Wellbeing Programme Board, Local Government Group, Jo Webber, Deputy Policy Director, NHS Confederation, Dr Frank Atherton, President, Association of Directors of Public Health, and Dr Keith Reid, Co-Chair, Public Health Medicine Committee, British Medical Association, gave evidence.
Q135 Chair: Good morning. Thank you for joining us. Could I ask you, briefly, to open the session by introducing yourselves and telling us where you come from?
Councillor Rogers: I am Councillor David Rogers. I chair the Community Wellbeing Programme Board of the Local Government Group. I am a county councillor in East Sussex.
Jo Webber: My name is Jo Webber. I am Deputy Policy Director at the NHS Confederation.
Dr Atherton: Good morning. I am Frank Atherton. I am a Director of Public Health up in Lancashire but I am also the President of the Association of Directors of Public Health.
Dr Reid: Good morning. My name is Keith Reid. I am a consultant in public health in Bristol and I am the CoChairman of the BMA Public Health Medicine Committee.
Q136 Chair: Thank you. I think you all heard the previous evidence session, or some of it. One of the issues that came up there was a discussion about whether Public Health England should be seen as part of the Department of Health or whether it should have a more independent status in order to provide it with a degree of separation between Public Health England and a Whitehall Department. Could we open the session by asking what position each of your bodies takes on that question?
Councillor Rogers: Thank you. We would certainly support it being an arm’s length body. That would allow for there to be more clearlydefined relationships between Public Health England and the public health responsibilities of local government. To that end, we supported an amendment-when the Commons was last discussing the Bill-to that effect, which, as you will know, was not successful. That position has been one that we have supported for quite a while.
Jo Webber: We would think that an arm’s length body may be one way of doing this. The most important thing is to ensure that there is an independent voice there, that the advice given by Public Health England can be independent and that it can be a strong voice for health protection and health improvement advice.
Dr Atherton: We support everything that Professor Heymann mentioned for pretty much the same reasons. It is important that Public Health England is not just independent in terms of its advice and its information but that it is perceived by the public to be independent. We believe that the risk of the loss of funding streams is a significant issue. We also see the construct of Public Health England, either as an NHS special health authority or an executive agency, as being a solution to some of the problems of loss of capacity that was coming to be apparent at the end of the last session because it could then be a host for public health staff across the board. We are very supportive of it not being part of the Department of Health.
Dr Reid: To continue the theme, we would be very strongly supportive of Public Health England being an NHS special health authority, a key reason being to establish the independence of the advice which emanates from Public Health England. A further reason would be to ensure that it can accommodate specialists across all three domains of public health practice. At present, it is focused largely on health protection and health intelligence issues and not seeking to embrace those in health care public health. We feel that they have a place in a public health service. The third reason is largely to ensure that there is a better interface between Public Health England and the local delivery of health services and public health services. We feel that would be better accommodated by Public Health England being an NHS body.
Q137 Chair: Can I ask each of you again, perhaps in reverse order because it might be more interesting, what would that look like if it were separated in some way from the Department? Would it employ the public health workforce and second them to local authorities? How deep into the system would this organisation go?
Dr Reid: Our key concern is that it should act as a welcoming home for the public health specialist workforce, so it should employ them. Since the bulk of the specialist workforce is employed within the National Health Service at the moment, we would see creating a body, probably within the NHS, as being a very easy way of making the transition. It simply involves gathering up the public health specialist workforce into a body which is part of the organisation which already employs them rather than creating special arrangements.
Q138 Chair: Is there not a danger, just to challenge that, that if you do that you lose one of the bits of value added intended in the proposals, which is to engage the public health professionals more actively in local authority decision making?
Dr Reid: I absolutely accept that that is a danger. My counter to that would be where we see the engagement with local authorities working well at the moment. It is working well with the public health specialist workforce coming from an NHS base. It is working well because the public health workforce in the NHS is acting right at the interface between local authorities and external bodies, so it is causing local authorities to face outwards in addressing public health issues.
My concern is that by absorbing the specialist workforce into the local authority and saying, "Public health is daytoday local authority business,"-which of course it is-the public health specialist workforce becomes simply an adviser to the local authority in the same way that the solicitor or the legal expertise within the local authority, delivered by highly qualified professionals and impacting on all aspects of local authority business, is not seen necessarily as an executive function of a local authority. It is seen as a supporting function. My concern is to ensure that the status and importance of public health are protected. We have seen evidence from the current joint working arrangements that that can be accommodated within a model which employs the director of public health in the NHS.
Dr Atherton: I have a similar view in that the bigger risk in the system, as currently proposed, is the fragmentation of public health. Keith has talked about the three domains of public health and there is a real worry in the public health community that health improvement staff are going to move to the local authority, health protection staff may move to Public Health England and nobody quite knows where the staff who will support GP commissioning-the health care public health people-will sit in this new system. We regard that as a bigger risk than the risk of loss of ownership by the local authority.
Ownership is really important. I think all our organisations have welcomed a greater focus within local authority on public health and greater leadership of the public health agenda. Thus, ownership of the staff is really important but that can be achieved just as well through secondments and arrangements, which currently exist in various forms, as they could by direct employment. At a stroke, it would solve a lot of very difficult and deep HR and transitional issues.
Jo Webber: We would probably be supportive. The main thing is to get the system working well locally. It may be down for local agreement as to where the public health specialist sits for pay and rations. The most important thing is to ensure that we don’t lose all the bits that have been talked about before, making sure that the evidence base used in commissioning health interventions is still there locally and available, but also making sure that the links are stronger between the GP commissioners and the local authority commissioning package, whether that be straight public health or other things like housing support services, leisure and those sorts of services as well. I don’t think we would say necessarily that people need to be employed within the NHS or within the local authority. It needs to work for local systems and there needs to be some recognition that, locally, this needs to be very clear about how all the domains of public health are delivered.
Councillor Rogers: From a local government perspective, we recognise the concerns that Dr Reid and Dr Atherton, in particular, have mentioned about where the expertise should sit and how that should then be deployed. For us, the most important point is the intended integration of public health within local government. If that is the underlying principle, then it doesn’t seem logical that the employment issues should lie elsewhere.
Of course, there is almost inevitably a transitional process and it might make sense for the employment, during a transitional process, in order to make sure that that expertise and competence and all the rest of it is not lost, to lie elsewhere. But, in the long term, for the very reasons that, as I understand it, these changes are being proposed, it is all about the integration of the public health function and the wider health determinants. Obviously, those are affected by housing, planning, the environmental situation locally and all those sorts of issues. It doesn’t make sense for the employment in the medium to long term not to be with local government as well.
Q139 Chair: On that model, what then would be the model of the independent agency? What would Public Health England look like on your model?
Councillor Rogers: The independence of the public health professional I don’t really see as an issue that is significantly different from the vast range of other independent advice that is offered to members of local authorities before they make sometimes very difficult decisions about how resources are allocated locally. There are something like 480 professionals that currently work in local government. They are all valued and they are all subject to professional competencies, training, ongoing professional development and all that sort of thing. I don’t see it as any different in the longer term, as I said, to those. The maximum benefits would be derived from a full integration of the public health workforce within that system.
Q140 Valerie Vaz: What about the budget? Are you in favour of ringfencing the budget or not?
Councillor Rogers: "What about the budget?" That is an excellent question. There are at least two issues there. The first of them is that although some work is underway, as I understand it, to identify what the baseline is, we don’t yet know the outcome of that and, therefore, we don’t know. A figure of £4 billion has been speculated upon. The BMA, when we met public health representatives at a round-table last week, were talking of £5 billion as being the current situation. The real issue is that we don’t know what the totality is. The question, beyond that, is: how much of that would be transferred to local authorities in order to have this responsibility and how much would be retained by Public Health England-whatever format it might have-in order to undertake the national responsibilities? The first question is to identify the total sum and then to ensure that the necessary resources are allocated to deal with the functions, however they are decided upon.
Q141 Chair: Almost by definition, it implies that we are talking about an inadequately defined range of functions if we don’t know how much we are currently spending on them, doesn’t it?
Councillor Rogers: Yes.
Dr Atherton: On the budget, I agree that £4 billion is a somewhat artificial construct, but there is work going on by the Department of Health-and it has been trialled in the north west-to look at what is being spent on public health. There is clearly more work that needs to be done on that.
Your question was about the ringfencing, I think. The ringfencing from the directors of public health point of view is useful, probably in the short term. It is useful at the moment, particularly to protect resources from being stripped out in PCTs as they merge into clusters and move towards 2013 and their ultimate demise. It is also useful, we believe, in terms of the local authority, to protect that resource in the short term until directors of public health are properly embedded and can make the argument within the top levels of local authorities, that these programmes need to continue. Otherwise, there will be a significant risk that in some places they may not be seen as high priority.
In the longer term, the real challenge is for the whole-the totality-of the local authority budget to be geared towards public health improvement and public health protection. In the longer term, I don’t think that public health ringfencing is a particularly productive concept.
Q142 Chair: Is or is not?
Dr Atherton: It is not in the long term. It is useful for transition, I believe.
Q143 Chris Skidmore: What do you think of The Lancet’s argument that the local authorities might re-designate services as public health so that they could effectively asset strip?
Dr Atherton: That is what I was alluding to. It is quite easy to see a pothole filling as a public health intervention, isn’t it? There is a risk, but what I would like to see in the future is that directors of public health would be in there making the argument that we should not be raiding sexual health budgets or immunisation budgets to pay for potholes. There is a sense of "last man in" and it will take time for directors of public health to achieve the voice in local authorities that they would need to make those arguments.
Jo Webber: There is also an issue about this being a developing relationship. While it is a developing relationship and people are trying to build trust and new ways of working, supporting that money within a ring fence might be something that helps to develop that trust and that different way of working and integrating together. It is almost allowing people the space to then start thinking about, "How do we use the wider budget in a different way to develop better public health interventions?" But you may well need the ring fence in the short term, and only in the short term, to give people the space to develop new ways of working in their new partnerships and the new health and wellbeing plan based on a strategic needs assessment.
Q144 Chair: Others want to chip in, but can I ask you to bear in mind that a ring fence was once described as a fence made of rings. I wonder whether it creates a false sense of security and that you need to be able to make those arguments in reality from day 1.
Dr Reid: The point is well made that there are two elements to this. There is one to ensure that those services currently delivered elsewhere-which are badged "public health"-for which responsibility transfers to the local authority, the funding for them is clearly identified. Those services are protected. There is a longer term issue around bending the culture and the way of working in local authorities so that our consideration, every time a pound comes up for spending is, "What is the public health gain or benefit from spending this pound?" The two things go hand in hand, one on a longer timescale and the other one is about protecting vital and important public health services during the transition. That is what we mean when we talk about protection of public health budgets, whether that is transitional or whether we see that as being a longerterm solution.
Councillor Rogers: We have all used the word "transitional" and I understand it in that context because I understood Dr Atherton to say that one of the issues was protecting the baseline before any transfer. That may well be an issue but, in the longer term and in principle, we don’t believe that the money should be ringfenced because if the objective is integration-as I was explaining a few minutes ago-it makes sense for the budget to be seen in that way as well. Also, that ties in with a much wider view that is held by the Local Government Group about all taxpayerfunded spending, that there should be a sense of place that is brought to bear upon it and that is the most effective way of using the taxpayers’ pound.
Chair: We never thought you might make that point.
Q145 Rosie Cooper: I have real worries-and I accept the argument in theory-about the practice. As a member of a health authority, we had a big meeting with councillors, the community and every strand of person with an opinion represented however that was constructed. With an economically-reducing pot, we looked at how we would deal with the health pressures across a health economy. At the end of it, no matter who you were or what you did, cardiovascular disease was at the top and sexual health or dentistry was at the bottom. We all looked at each other and said, "This is not the model we want to describe or want to have, but, with financial pressures, that is where we are."
You are going to move into a situation where finance is really tight. I know we can all work smarter-we’ve learnt all that rubbish-but, at the end of the day, councillors will be forced to choose between X and Y. You are not, surely, going to say that you are sure things like sexual health will not end up where mental health is in the Health Service currently-the Cinderella service on the edge because you can’t see it and it’s not in your face every day. It will fall off the end and money will be used for other resources which local taxpayers want. The Council Tax payers will want their roads fixed and will want X, Y and Z done. One person at director level is not going to be able to deliver down to that degree under that kind of pressure. Or is that what you are telling me?
Chair: That one is probably directed at Councillor Rogers.
Councillor Rogers: I am happy to start. There are two things I would like to say there. First, we have not yet talked about Health and Wellbeing Boards, the joint strategic needs assessment and the strategy that would then derive from that.
Chair: I have to say that we don’t plan on spending very long on those this morning.
Q146 Rosie Cooper: No, but the Health and Wellbeing Board has no power whatsoever. It only has power to talk.
Councillor Rogers: We don’t know that yet.
Rosie Cooper: It is a powerless talking shop.
Councillor Rogers: We don’t know what the shape of the Bill might be in due course. The point there is that-
Q147 Rosie Cooper: Hopefully it will disappear.
Councillor Rogers: If the joint strategic needs assessment identifies sexual health or any of the other Cinderella services as being a priority for that area-and they might well do in a particular area-that would inform the commissioning processes, both for the intended GP commissioners and for the services that local authorities commission. That is, if you like, the principle. Of course, I accept your point that we are in a time of unprecedented strain on public finances and that there could well be some casualties. But we can’t sit here and say what that would be. That would be a matter for local determination through the structures that are intended and judged against other priorities. That has always been the case in relation to public spending whoever is making those decisions.
Q148 Rosie Cooper: We need to go to bed praying not to be suffering from anything that is not a priority then.
Dr Atherton: Can I perhaps give a little comfort? One thing to say is that the public health budget has never been terribly safe in the NHS. It has been a low priority. We know that. You will remember back to Sir Liam Donaldson’s report, which talked about the raiding of public health budgets when times got financially tough, round about 20056. We remember all that. It has not fared very well historically, even though we intuitively know that better spend on prevention will lead to better health outcomes and will reduce the need for highcost tertiary care. We never quite get there in the NHS.
There are examples in local authorities, even in tough times. Very recently-one very specific example-Lancashire County Council decided to make all roads in residential areas near schools and other residential areas 20 miles per hour zones because they were convinced by the evidence that it would reduce road traffic accidents and, particularly, that it would reduce road deaths for children in more deprived areas. So there are examples where you can use evidence to bend the mainstream, and that would cost several million pounds, in a time of hardship.
Rosie Cooper:: Absolutely. As a Member of Parliament who, unfortunately, has to deal with Lancashire County Council, that might be a really great decision but it will take eons to deliver.
Q149 Chris Skidmore: That raises the question of the definition of public health. Many people would say that the public health budget should not fund road reduction schemes-that it is not necessarily a public health issue-and would question that. It does come down, also, to the Government’s new outcomes framework which will help to decide its public health remit. In particular, Councillor Rogers, I was interested in the Local Government Group’s idea of a single outcomes framework, having the NHS, social care and public health. I know you have talked about integration, but I was wondering if you could give a bit more explanation of your reasons.
Councillor Rogers: You have hinted at the answer yourself already in that if the principle underlying all of this is integration of a pathway for a patient, a client, a service user-whatever term we choose-and we see it from that person’s point of view, what they want is something that addresses all of their needs, whether those have traditionally lain with the NHS, with social care or with public health. I really think that we ought to be looking at it from that end of the telescope, if you like. That is why we have argued for a single outcomes framework. Of course, there is a degree of evidence that there are similarities between the three that are currently proposed, and it is good that there are overlaps, but, in our view, having a single one would not only make the case for integration stronger but would also ensure that the commissioning decisions-as I said, whether those came from GP consortia or from local authorities, or indeed from anywhere else-would be addressing the real needs of that particular community.
Q150 Chris Skidmore: There is also an issue of the measurements that occur in the outcomes framework. In the evidence from the NHS Confederation, Ms Webber, you mention the issue of the time lag between implementation of policy and achieving those improvements.
Jo Webber: Absolutely. There are some proxies that you could use for the short term-and by "short term" I am meaning one, two or three years-but, with some public health interventions, it is going to take you 10 or 20 years before you see what that outcome might be, by which time you are going to have had probably two or three changes of idea about which way this is all going. Therefore, there is an issue about getting the right proxies in place as well in the short term and then allowing the evidence base to be built. Over the long term, you can change and refine the outcome so that you get something which really does give you a feeling for whether you are meeting the needs of local people. It is a very different timescale from, say, the NHS outcomes framework, where a lot of this is about how much you meet within a set period or over the course of a year. With public health it is a completely different timescale. It is a completely different partnership that you need to have working together to deliver any one of those outcomes.
Q151 Chris Skidmore: Could I quickly then roll on to the next question which is on the specific issue of taking a set period of time? We have the issue of the health premium. One thing I have noticed in the evidence put before the Committee here is that all of you use the words "unintended consequence" in your evidence. I was wondering if you might be able to give a better explanation about the concerns you have with the health premium. We have our own concerns, but it would be interesting to hear what your views are on this.
Dr Reid: As to the health premium in concept-the idea that it should be a reward element for improving local health, reducing health inequalities-the wording used in the consultation document was it would be devised by a simple formula. My problem is that I can’t see how a simple formula can lead to such an important element being devised. I am concerned about how we measure change. How will we establish where we are and where we have got to over the fixed time period for which the health premium will be given? I have concerns about measuring reliably over historical periods. I am concerned that it will be given retrospectively, so you will get a reward for something which has happened previously. It is not linked to current practice or devised in such a way as to incentivise innovation and bold attempts at addressing inequalities. I am concerned that, as expressed, there is not a link to the size of the problem. We know that health inequalities exist everywhere, even locally in Westminster, but the number of people affected by health inequalities is the number of people in poor health, and to be in poor health is different in different places, despite the existence of health inequalities. Therefore, I am concerned it needs to be linked to the number of people whose health status has been improved as a result of specific actions rather than just reducing a gap.
Dr Atherton: I have similar points. The ADPH point of view has been very clear. We should be looking to target extra funding towards need rather than to reward good health status. If we are going to use it as a performance reward, then it should be based on relative improvement rather than just absolute health outcomes, for the very reasons Keith said. It is easier to improve and have a good health outcome in leafy Fylde in Lancashire than it is in parts of east Lancashire.
Jo Webber: We don’t disagree.
Q152 Chair: We probably don’t need to hear the same point repeated. Is there a different point? Do you agree with it?
Councillor Rogers: I do agree with the need to differentiate between good and bad areas, but the other issue is whether it would be based on local outcomes or national outcomes. Obviously, I would argue the localist case-you wouldn’t expect me to do otherwise on that-and also to ensure there was some way of reflecting the diversity of communities. Often health inequalities occur in very specific pockets within a wider local authority area. That is an important point to bear in mind too.
Jo Webber: There is also an issue around some inner city areas where the churn of turnover of population is such that you can never improve because, as people improve, they leave and more people and more deprived groups come in. You never get an improved outcome, even though you are doing well in terms of your health improvement activity.
Dr Atherton: People are not ring-fenced.
Chair: They go through the rings.
Q153 Grahame M. Morris: Councillor Rogers and Jo have covered the issues there. The Committee went to Hackney and Shoreditch and that was the point I wanted to make. My area is fairly stable and does not have the turnover-although we have had huge problems with health inequalities often associated with heavy industry and so on-but where there is a huge transient population, it does not make any difference how good or targeted the health interventions are. As you say, populations aren’t ring-fenced. We appreciate that.
Jo Webber: It may be that you need several different kinds of incentive depending on what your population looks like.
Q154 Chair: Can I come back to one of the structural questions and the impact on a specialist workforce? Is it the LGA’s view that local authorities should be free to appoint people that satisfy their tests to this public health function, or do you think that appointments to the public health function should be required to be from certain specialisms defined elsewhere? Secondly-a different but related point-if a director of public health in particular falls foul of his local authority, do you think there should be some safeguard to his position from some external body?
Councillor Rogers: I will deal with the first part of that first. As I understand it, the faculty currently accredits people both from a medical background and from other backgrounds. Provided that were to continue to be the case, we would have no difficulty with ensuring that any person who was to be appointed had been thus accredited. Nevertheless, we think it should be a local authority appointment. Again, I come back to the point that if the responsibility and the accountability is to be there, which is where I believe it should be, then it doesn’t make sense for there to be in the long term-and again we might need transitional arrangements-anything other than the appointment and, in extremis, dismissal processes that apply elsewhere. Of course, the latter is not something to be entered into lightly or without the proper engagement of partners. Who those partners might be is one of the uncertainties that we all know surround much of this.
Q155 Chair: You don’t really support any kind of dual accountability to local authority and Public Health England?
Councillor Rogers: There is a difference between line management accountability and professional responsibilities. Again, I would make the comparison with a whole range of other professions where the people concerned would be in very close contact with their professional associations.
Q156 Chair: That is a different point, though, isn’t it, the professional association and the accountability to Public Health England as an executive agency?
Councillor Rogers: Indeed. In that case, I am clearly arguing that the responsibility should be local.
Dr Atherton: I will deal with a couple of your points. One is about the requirement that certain standards are met for a director of public health. Councillor Rogers is absolutely right. The current position is that the faculty approves that. We are truly multidisciplinary-we have medical and nonmedical directors of public health-and that has brought a great strength to the profession. But, as directors of public health, we make decisions which impact on the health of our populations. We provide advice which needs to be quality assured. We are strongly of the view that the current system for regulation is really important and that that remains in place, that directors of public health are properly trained, accredited and appointed to-
Q157 Rosie Cooper: Should there be a statutory register?
Dr Atherton: We believe that, for all directors of public health, it should be on a statutory basis. They should have statutory registration. In fact, we go beyond that and apply that same principle to the public health specialist workforce. At the moment, medically qualified directors of public health and consultants are statutorily regulated. Nonmedical equivalents are not. I think there should be the same playing ground for everybody.
Your point about the dual accountability, though, is somewhat problematic because we don’t really understand where the director of public health role in respect of health protection would be in the future. If the director of public health is going to have a significant role in health protection, as we believe they should because we certainly do at present, then they need to be officers of Public Health England as well as an officer of the local authority. We believe that dual accountability is quite important to discharge those functions. However, it is not entirely clear, as I sit here, what the future arrangements are for health protection and what the future intended role of the director of public health is around health protection. That is a major issue and concern which we need to address as soon as possible.
Q158 Grahame M. Morris: Can I seek some clarification as to your views in relation to emergency preparedness? You were in for the earlier session and I think it was Professor Heymann who said-and he was sitting where Councillor Rogers is sitting now-when we asked about the category 1 responders, that it was kind of a work in progress. He said Public Health England should be a category 1 responder, that there should be a coherent response at local level and that it was still being worked on by the Government. I am sorry to go on about E.coli-I am becoming obsessed by it-but where there is a significant disease outbreak or there is a public health emergency, how would this emergency preparedness be tackled at a local level under these new arrangements? Should it be a local lead or a Department of Health, Public Health England lead?
Councillor Rogers: Of course, if we are looking at examples elsewhere, such as in Germany, the clarity is not there, is it? I am not entirely convinced that there is the clarity under the existing arrangements that there should be. To my mind, this is another example of where greater clarity in the detail of the proposals is needed, and we have touched on that in relation to a whole range of other issues already.
Q159 Grahame M. Morris: What is your preference? Should it be at a local or a national level?
Councillor Rogers: I think the two go hand in hand because, even if you have a degree of national responsibility for such incidents, you can’t deliver that without the engagement of the local authority and other partners at local level. It needs to have everyone involved in a partnership arrangement, but that does need to be defined very clearly, to answer your fundamental point.
Dr Reid: It is quite clear who is responsible at the moment. It is the director of public health who is legally responsible for mounting the response. Under the proposals, that should continue. On the face of the Bill as it currently stands, there is a proposal to put responsibility for health protection of the local population on to the local authority. The responsibility will then have to be exercised through a local officer. The key person to do that is the director of public health, who will have the skills, the training and expertise to do that.
The key words which David Heymann mentioned earlier were the duty to plan and prepare, which arises from the Civil Contingencies Act. It is about making sure that responsibilities are explicit, that each person knows the role they are expected to play and that they prepare to play those roles. Therefore, when an incident does arise, it is a welloiled machine which springs into action and we are not sitting around thinking, "It would be good if we had a plan. Let’s come up with one now."
My concern is that, as currently proposed, Public Health England will stop at the level of the Health Protection Unit, which will not be at a local authority level but will be sitting above a number of local authorities. There is a potential difficulty at the interface between Public Health England and the local authority under the current model and the idea is that that should be bridged through the person of the office of the director of public health. How can that person do that effectively unless they have a good relationship with Public Health England? One way of establishing that good relationship is through accountability. An even better way would be by employing them through the National Public Health Service and seconding them out to local authorities. That is the model we prefer. If they are not going to do that, they need to have accountability for the health protection line up through Public Health England to the Secretary of State. There is no problem with having that accountability, regardless of who the employer is.
Jo Webber: Can I pick up the point about the Health Protection Units and having clarity and some idea about what the relationship is going to be like between the director of public health and the Health Protection Unit locally as well? That might deal with some of the issues about the loss of a regional tier in all of this, which is obviously something that is exercising people. That relationship between the HPU and the director of public health is going to be all important.
Dr Atherton: Can I reiterate one point? It is a point you made earlier, Mr Morris, about leadership. When something goes wrong on the patch, you need somebody to take charge. At the moment-Keith is absolutely right-it is the director of public health. That needs to continue in the future. What we need to know is whether the organisational responsibility sits with the local authority or with Public Health England. That is not entirely clear yet.
The final point-I am sorry to add one extra-is that, at the moment, we make things happen to respond to incidents largely through goodwill, our relationships and our contacts, but primary care trusts, of course, are category 1 responders. In the new system, we would suggest that all NHS bodies, both commissioning and NHSfunded providers, need to have the same duties to respond to public health emergencies that currently sit with primary care trusts, otherwise the leaders become weaker and it gets harder to get things done when you need to.
Q160 Rosie Cooper: I have a practical question. When you have difficulties with winter pressures and hospitals getting clogged up, how do you see that working in this new world? Let’s say there is an outbreak of something-I do not know what-hospitals are getting clogged up and you need to get people moving. How are you going to deal with that?
Dr Atherton: I will kick off. Again, this is one of the key scenarios. I think Professor Heymann talked about some joint work which the Association of Directors of Public Health and the HPA have been doing, and that is one of the scenarios we have been looking at. In the current circumstance, we have an SHA which would coordinate that, hold to account the acute trusts and coordinate the efforts of community providers-of everybody. There is a potential weakness in the system because we don’t know who will hold that role in the future. Will it be the National Commissioning Board? Will it be Public Health England? As part of that transitional risk, and until we know quite how Public Health England is going to be constructed and what the responsibilities of the local authorities are, I don’t think anybody could tell you how that will be managed.
Rosie Cooper: Absolutely, and obviously that is the point I was making. There is a huge risk here because you are going to have a lot of people running round with nobody, in this interim period, having the power to make it happen.
Q161 Valerie Vaz: Can I move the debate on slightly? Both Dr Reid and Dr Atherton mentioned, in their opening remarks, that no one seems to be talking about health care public health. Could you explain why it is so important, how the system runs now and how you see it under the new NHS commissioning role?
Dr Atherton: Currently what happens is that, within public health teams, there are consultants in public health who specialise in things like needs assessment work, prioritisation, bringing an ethical dimension to commissioning and helping to support prioritisation of investments and disinvestments. These are really important things, especially in a challenged financial environment. If we are going to meet the £20 billion socalled Nicholson challenge those kinds of skills are going to be really important to GP commissioners in the future.
At the moment, they are provided as "free goods", really, through PCTs. It is variable. Some places are very well resourced in that regard and some places very poorly resourced, so there is some variation. But there are a number of models starting to emerge which might be possible. One is that if those public health staff people move into the local authority, they could be provided back to the GP commissioners to support their work. There are places where GP commissioners are looking to directly employ public health consultants, but that raises the spectre of a lone employee. There is a possibility that they could look to the private sector-these are people who have very specialised skills who could find a home for themselves, should it be needed, in the private sector-and the point that was made earlier about buying back resource more expensively from the private sector could well happen. Our preferred option would be to keep that resource as part of the public health workforce: to keep an integrated workforce and have it available to provide back to the GP commissioners to support their work.
Dr Reid: Can I follow that up? I suppose I should declare an interest because I do work full time in health care public health at the moment supporting the South West Specialised Commissioning Group. The key thing for this group is that it is a small number of individuals who do this full time. There is a larger number of individuals who will do this as part of their role and may take the lead in one aspect of health care-for example, diabetes or obesity-and be involved in commissioning services through that. There are smaller groups of individuals, like myself, who do it as a fulltime specialism.
The key is to make sure that we don’t lose this resource. The other key is to make sure it is organised in such a way that there is a critical mass and we don’t have the situation which we have had in the past where we have had individuals become isolated and become ineffective as a consequence. The way to do that is to look to create a single home for the specialty health care public health, or perhaps two homes. One would be in the National Commissioning Board, where a health care public health function would sit quite happily along with the other clinical advisory roles which are going to be provided to that Commissioning Board. You could see that as being a smaller cohort of specialists, perhaps including those who currently provide specialist Health Service advice like myself, numbering about 15 to 20 across the country. The other home would be a larger number of about 180 who could form a central resource available to health care commissioners. Against this, a model of having an independent employer of the specialist public health workforce has advantages because it would allow those individuals to be employed as a single central resource and seconded out on a contractual basis to others to provide health care advice to them. It would enable them to maintain their professional skills and expertise; it would enable the critical mass to be maintained; and it would identify them as being independent of other interests so that their advice could be seen to be impartial and independent. Those are the preferred models. There are other models which Frank has alluded to but these would come further down our list of preferred models.
Q162 Valerie Vaz: Why do you think the White Paper and the Bill were silent on this? Why is there this big gap and no one is talking about it?
Dr Reid: I think it is because there is a lack of understanding of the scope of public health. It is wider than simply encouraging communities and individuals to live fulfilled and healthy lives and protecting them from infectious and environmental hazards. It is also, critically, about ensuring they have access to appropriate, affordable and quality health care at a local level. Public health has always been about those three aspects. The White Paper reduced it to two aspects and health care public health disappeared. It is because there has not been that appreciation that public health specialists deliver across all three.
Q163 Valerie Vaz: What representations have been made to the Secretary of State about that?
Dr Atherton: We have made very clear representations to senior civil servants and to the Secretary of State himself. He understands our concerns, I believe, on that. He understands that we are arguing for an integrated system rather than a fragmented system. What we have not seen yet is a response to the consultation on the White Paper because that has not yet been delivered.
Dr Reid: To my mind, that is the key when we talk about the public health service. The public health service needs to embrace all three domains. That is the point that we opened with. It is not a public health service if it only embraces two of them. It is delivering a health improvement and health protection function but it is not a full public health service. That is a message we have sent repeatedly, but it is a struggle to get it understood.
Q164 Yvonne Fovargue: I would like to go back on to the fragmentation. The NHS Consortium has said that you are concerned about fragmentation of certain services. You said that people’s needs may fall through the gap here, particularly immunisation, sexual health and dentistry. Could you say why you have used those as examples and where you see the problems?
Jo Webber: There are some services, at the moment commissioned together, that are going to be commissioned in three different places within the new system. If you look at sexual health, HIV and AIDS services, they are going to be commissioned through the National Commissioning Board. Genitourinary medicine services are going to be commissioned through the consortia. Teenage pregnancy and other services probably are going to be commissioned through local authorities.
There is something about bringing those bundles of public health services around a particular specialism together in one place. If you are not commissioning them in one place, you have to bring them together somewhere, which brings us back to, "Is there a role for the Health and Wellbeing Board? Is there a role for the director of public health working with Public Health England to make sure that this is all linked together?" This is particularly for sexual health and dental services as well, which is in the same situation. General dental practitioners commission nationally and community dental services, like school dental services, are commissioned by the consortia, dental public health being commissioned through the local authority. It makes no sense when you are looking at it from the patient’s point of view, or the individual’s point of view, that you could well find yourself without a service because everybody thought somebody else was doing that particular bit of it. You need to be able to bring these together in coherent bundles.
Q165 Yvonne Fovargue: What would be your preferred solution to that?
Jo Webber: There is quite a lot of this that could be done at local level-I don’t think everything has to be done through the National Commissioning Board-or at least at a regional level with an input that brings it all together. Maybe that is one of the roles of the director of public health when we are talking about the health care elements of public health as well, to ensure that the commissioning of this is brought together locally and understandable to GP commissioners and local authority commissioners so that we don’t get services with holes in them.
Councillor Rogers: I agree with what Jo Webber has just said. I would like to present another example to you, and that is the whole issue of children’s health. As currently proposed, services for under-fives would be commissioned by the National Commissioning Board and for five to 18-yearolds would be commissioned locally. To us, that doesn’t make sense. There is obviously a serious risk of a gap developing around the age of five, and it doesn’t make sense for school nursing to be in one place and health visiting to be in another. We would argue, as Jo was saying just now, that much of this can be done at local level. There might be need for some coordination arrangements at something above that, but sub national, and we certainly wouldn’t want to see the artificial creation of any gaps.
Q166 Yvonne Fovargue: The Local Government Group has said that too much has been commissioned nationally and not enough locally. How would you draw the lines and how would you allow for local variation but also have a strategy that would cover various areas as well?
Councillor Rogers: This is about subsidiarity, isn’t it? Everything that can readily be commissioned and provided locally should be. Where there are strong arguments, as there are for some acute services, for arrangements that are at a level beyond that, then that would be the responsibility of the professionals to ensure that was put in place. But we would start from the point of view of maximum locally and devolution upwards, if I can put it that way.
Q167 Rosie Cooper: If I might go back to the question Chris asked about a single outcomes framework and some comments made by Dr Atherton before, just trying to bring it all together-and I am being devil’s advocate-how would you manage the situation? How would you differentiate between what some people would call a real health outcome and some might call prevention? Using the example that Dr Atherton gave before of the 20 mileperhour zones that Lancashire County Council say will save the lives of children round schools, that very same council is also decimating Dial a Ride, for example, which leaves elderly people in a rural area like mine with very little help. It will probably cost £5 for a trip to get to their doctor or to get to hospitals, and there’s the social isolation. There are real health outcomes which happen today as a result of that decision, not a prevention agenda. How do you make those decisions and defend them to the people who are paying that Council Tax who are desperately worried?
Dr Atherton: My answer has to be in general terms. The architecture that is proposed in the local authority seems sensible. I hear your scepticism about Health and Wellbeing Boards. I have been involved in Health and Wellbeing Boards for a number of years and many of them have been talking shops, I absolutely agree. But there is a chance now to do something different. That is why we have been arguing-I think probably most of the organisations represented here, if not all of them-that local authorities and Health and Wellbeing Boards should have some form of signoff of what GP commissioners are about. That is one point.
The other point is that the health and wellbeing strategy should bring those priorities into stark relief and should be a way of trying to make those relative choices. I suppose councillors have been making difficult choices for years, but we need to make it more explicitly and more based on evidence.
Q168 Rosie Cooper: If you have signoff on what we would like to call NHS commissioning authorities, should they have some signoff on local authority decisions, such as what I would consider is a desperately bad decision to deprive old people of their ability to get about?
Dr Atherton: It is a good question and David, I think, has the answer to that.
Councillor Rogers: You wouldn’t expect me to comment specifically on the budget decisions of a member authority of the Local Government Association. However, in principle, there are tough decisions that need to be made, especially in the current Spending Review period. I am sure all of you will be aware of the 25% or 28% reduction in funding for local government, and these tough decisions need to be made.
Q169 Rosie Cooper: I get all that. We have all heard those tapes. The problem we have right now-the question I am asking-is the difference between you making a decision, which is possibly about prevention, and you making a decision which will have a real health outcome today.
Councillor Rogers: Yes. I agree there with what Dr Atherton said, that the Health and Wellbeing Board should have signoff on local commissioning for GP consortia, clinical consortia-whatever they might be in the future-but also on the commissioning intentions of the local authority in relation to these matters.
Dr Reid: There is another point here which is about accountability and responsibility to the population. If it is the local council and local councillors who are making that decision, that needs to be explicit and then the way for accountability to be exercised is through the ballot box. But that raises the question of what advice councillors base their decision on. They may have chosen to ignore very wellfounded advice or they may have chosen to take into account advice of the consequences and press ahead regardless. There is a role here for the director of public health being able to be independent, albeit slightly distant, from the local councillors and being able to make clear the advice that was given to councillors in arriving at a decision. That will help in clarifying processes that lead to contentious decisions and in being clear where responsibility for those decisions lies.
Chair: We are now into the management of commissioning processes. We have probably spent enough time, as a Committee, on that for the moment. Are there any other questions?
Q170 David Tredinnick: I have one other question on a separate but related subject to do with the Scally report, the "Review of the Regulation of Public Health Professionals". Scally recommended statutory regulation of public health specialists but the Government favours voluntary registration. What positions do your organisations take on this issue, please?
Dr Reid: We favour statutory regulation of all public health specialists and, additionally, we would like to see the Scally recommendation for protection of the title of director of public health.
Dr Atherton: Ditto.
Jo Webber: The same here.
Councillor Rogers: Yes.
Q171 David Tredinnick: Can you expand a little on why is it so important?
Dr Atherton: It is the point I was making earlier. It is a public safety issue. If you were going to see an orthopaedic surgeon or you were being cared for by a nurse, you have an expectation that those people will be trained or accredited to certain professional standards and that they will be in a properlyregulated profession. It is the same with public health for the reason that I mentioned earlier. We are providing specialist advice on which decisions are made and if the wrong decisions are made that adversely affects people’s lives and health.
Q172 David Tredinnick: Do you think there is a case for allowing health professionals who are registered with a nonstatutory body but a body that is recognised by the Government as an authoritative body?
Dr Atherton: Are you talking about outside of public health now? We are making this argument for public health specialists, but for public health practitioners the general view that I have seen is-and it is certainly the view of the ADPH-that voluntary regulation, voluntary registers, etcetera, are appropriate.
Q173 Chair: How far down below the level of the director of public health would the requirement for a-
Dr Reid: Directors of public health and consultants in public health or public health medicine.
Q174 Chair: Yes. The director of public health might not be a doctor but a consultant in public health medicine would be a doctor.
Dr Reid: The director of public health should be trained to the status of consultant in public health/public health medicine. The distinction is whether they are a doctor or not. Not being a doctor is no bar to being a director of public health and being a doctor is no guarantee of being an excellent director of public health, I add quickly being married to a nonmedical consultant in public health. Below that is the level of consultant in public health with the rider of "medicine" if you are a doctor. Some choose to use it and some choose not to. That is the specialist workforce.
Jo Webber: Bearing in mind that people like health visitors are obviously already registered as part of the NMC.
Q175 Chair: Do we have any other concluding questions or comments?
Councillor Rogers: Could I make one comment? The Association of Directors of Children’s Services and ADASS-for adult services-are, I think, not represented here this morning but are saying very similar things to what you have heard from us this morning.
Chair: Thank you.
Rosie Cooper: They might have possibly got more of a roasting.
Chair: Thank you very much.