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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 694-i
House of COMMONS
TAKEN BEFORE the
Communities and Local Government Committee
THE ROLE OF LOCAL AUTHORITIES IN HEALTH ISSUES
WEDNESDAY 21 NOVEMBER 2012
DAVID BUCK, DR NICHOLAS HICKS, GRAHAM JUKES,
DR JOHN MIDDLETON and DUNCAN SELBIE
Evidence heard in Public Questions 1 - 48
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Taken before the Communities and Local Government Committee
on Wednesday 21 November 2012
Mr Clive Betts (Chair)
Examination of Witnesses
Witnesses: David Buck, Senior Fellow, Public Health and Inequalities, The King’s Fund, Dr Nicholas Hicks, Milton Keynes Director of Public Health and Programme Director for Public Health at the NHS Commissioning Board, Graham Jukes, Chief Executive, Chartered Institute of Environmental Health, Dr John Middleton, Vice President, UK Faculty of Public Health and Director of Public Health, Sandwell PCT, and Duncan Selbie, Chief Executive designate, Public Health England, gave evidence.
Q1 Chair: Can we begin this session with declarations of interest? Members have their interests in the register of interests. I point out at the very beginning that I am a vice-president of the Local Government Association, and I put that on the record so you know where I am coming from in that respect. I welcome all of you to the first evidence session in our inquiry into the role of local authorities in health issues. For the sake of our records, could you begin by saying who you are and the organisations you represent?
Dr Middleton: I am John Middleton, vice-president of the UK Faculty of Public Health and director of public health for Sandwell in the West Midlands.
Dr Hicks: My name is Nicholas Hicks, director of public health in Milton Keynes. I also spend three days a week of my time as a consultant to the NHS Commissioning Board.
Graham Jukes: I am Graham Jukes, chief executive of the Chartered Institute of Environmental Health.
Duncan Selbie: I am Duncan Selbie, chief executive designate of Public Health England.
David Buck: I am David Buck, senior fellow in public health and health inequalities at The King’s Fund.
Q2 Chair: There are five of you and no doubt you will all have your own views on things, but if your views coincide with those of one of your colleagues you do not have to repeat them in detail. If you just say you agree, it helps us to move the business forward so that we can deal with all the questions we need to in a reasonable time. All of us here probably have local government interests but have not been particularly exposed to the issues around the reforms in public health, because it is a new transfer back to the local authority arena, but in terms of that fundamental, perhaps you would give us your view about the significance of the transfer of the role back to local councils. It did not seem to me that the average councillor would feel very much ownership of any of this, looking at the various proposals, accountabilities and responsibilities that we have in front of us.
Duncan Selbie: I have been in the health service for over 30 years and have worked with the public health community in various different ways, for example in psychiatry 10 years ago. It is inconceivable how you could offer care and access to treatment without working across local government and the health service. The opportunities to get into health outside treatment and early intervention are so much greater working through local government than where we have been for the last number of years.
My own experience of meeting elected members around the country suggests there is optimism and positivity. They have been saying to me that this is about the responsibility coming back home. The leader of Newcastle City Council described their priorities in three themes: creating jobs, decent neighbourhoods and tackling inequalities. One of the leaders in the Greater Manchester conurbation described how the next phase of economic strength in that area would only be possible by improving the health of the population. In Sheffield, they talked about spending £1.5 billion and being able to scale up 44,000 households, but not knowing quite what to do and looking to the public health movement to Sheffield City Council as their R and D function. I am sure that is not the case everywhere, but as I travel round the country I meet a great deal of optimism about this.
Graham Jukes: Public health is coming home. Local authorities were the originators of many of the public health interventions that created huge improvements in the health of the nation. Post-1974, when medical officers of health moved out of local government and into the NHS, many local authorities have forgotten the roots of public health improvement; it is about infrastructure and all the things that local authorities do so well. In many respects public health has become synonymous with public ill health, and we ought to be trying to get in front of the curve, as many commentators have said, to start addressing the causes of the causes of ill health, and that is through prevention. Local authorities are in the best place to do that. I am not sure many local authorities and councillors understand the history of public health provision in this country, or indeed where it can go to now. A lot of work needs to be done through the LGA and other mechanisms to make sure councillors understand not only the history but also the future.
Dr Middleton: We would certainly want to see health as an issue of civic pride for councillors. Life expectancy ought to be an important thing they want to achieve for their residents. It should be unacceptable if their life expectancy is not as good as it is in other parts of the country or in other parts of their council. The issue is to get councils to appreciate health as a matter of civic pride and necessity and what they should expect for their citizens.
Dr Hicks: It is important to recognise how fast health has been improving. In the 10 years between 1997 and 2007, expectation of life for men improved by over three years. That is 37 months in 10 years; in other words, expectation of life has been improving by over three months for each year, which is remarkable. During that period my perception working locally has been that although local government has always had many of the levers for improving health-education, housing, transport and so forth-it has not always had the confidence to use those levers to improve health, or seen that as one of its core aims. The great opportunity of these reforms is for councils to put the improvement of the health of their population and the narrowing of inequalities right at the core of their purpose in being there. If we can achieve that, it would be fantastic.
David Buck: I would reinforce much of what my colleagues have said. This gets to the core of what local government thinks of itself and what its purpose is. It feels to me that at the heart of it is primarily its stewardship of wellbeing, of which health is clearly one aspect. They are separate concepts, and there are some interesting issues about health and wellbeing boards. If you focus on health versus wellbeing, you will not necessarily choose the same things to focus on. Maybe we can get into that debate later.
When we talk to local councillors, they really get it. They want it and they are incredibly enthusiastic about it. It also particularly opens up opportunities for good conversations and joint working between GPs and local councils, which has often been hard in the past. Both of them come from a space where they are talking about small areas-their wards and patches. That conversation between the NHS and councillors has often been difficult before, because it has been primarily a relationship between the PCT, a much higherlevel body, and local councillors. There are some real opportunities, particularly with GPs and local councillors as they come to the health and wellbeing board, through the CCG role. It is a good question about the average councillor. The councillors I see are the ones who are enthused, not the ones outside the health and wellbeing board remit, so it is a good challenge and good question to us.
Q3 Chair: It is a simple question. In five years’ time, when someone comes along and says to a council, "You’re responsible for public health and all these inequalities. What have you done about it?" They will say, "Well, we’re not really responsible. The leader and some of our senior officers may be a bit involved in that, and we have Public Health England, commissioning groups and the NHS Commissioning Board." They all have their fingers in the pie. It is desperately difficult to explain the system to anybody. You could explain it all, but you are probably only five out of 10 people in the country who have any understanding of it. Isn’t the problem for the public that if something is not understandable it is not really accountable?
Graham Jukes: There is an issue about timing, transition and transformation. As we go into this next phase-public health will go to local government on 1 April-we are very much at the planning stage. There have been lots and lots of discussions about that. As we start to get the health and wellbeing boards firmly established, JSNAs beginning to drive the agendas for local authorities and the necessity particularly for district councils to be involved and engaged in the creation of local JSNAs to set strategies, we will see the emergence of a very clear understanding about roles and responsibilities, but we are not there yet. Once it is established, we need to provide the tools and information for councillors to understand their new role.
Dr Hicks: When I spoke before I said that if we can get councillors to put health at the heart of their purpose, that is a great prize, and it is, but it is an "if". There is still a risk that too many people see public health as just preventive services, health improvement or health protection and do not necessarily see the whole of the strategic content. One of the tests is looking at an existing council plan, which sets out the council’s ambition, and asking whether it wants the health and wellbeing board to help them deliver that plan, or whether they see the arrival of their leadership role for health as changing the council plan, so the council plan becomes much more focussed on health as a whole. As to that, there will be some questions about the relationship between the health and wellbeing board and the council. Which one drives which? Does the health and wellbeing board come up with one view and the council plan then reflects it, or do they look at it and say, "We’d rather do something else"? For me, one of the key tests of your question is: does the council really get its role as being the leader and responsible body for health in its community?
Dr Middleton: I would not want the Committee to believe that the five people assembled before it understand fully what this system is all about. There are large chunks of the system that are in flux and are still being devised and determined, and there are considerable risks in that. As to what councils need to do, we describe three domains of public health: health protection, which is about keeping us safe from infectious disease, communicable disease and major emergencies; health improvement, which is all the policies of the council and how we promote health and keep people healthy; and the domain of healthcare-related public health, where the analysis of what goes on in your local acute hospital is every bit as important as those other two elements. If councils are to be strategic leaders of the health strategy, they will have to be able to understand and challenge what goes on in the hospital on their behalf. Similarly, they will have to be able to support clinical commissioning groups by providing public health advice so that what goes on in primary care can be as effective as we would advise.
David Buck: There are three additional things that will help. One is that we know from most experience that local authorities are much better at engaging with their local communities than perhaps the NHS is. The experience I have had with health and wellbeing boards is that they have been getting all their systems in place, working out who is on them and the links between the JSNA and the health and wellbeing strategy. They are now starting to ramp up around public engagement, both with the public directly and more broadly with councillors. That is coming on stream, but we are asking a lot of health and wellbeing boards to do an awful lot of things. There is a danger that they are becoming Dr Johnson’s elixir-they will sort out all the problems locally, including health issues. We have to be careful about loading them up and expecting too much of them too quickly, but I think local authorities are much better at public engagement and that will come through.
Secondly, it is good to have Duncan here, and Public Health England and NICE, explaining the evidence about the things local councillors have control of through their political role in local areas, and how that translates to what they can do about it. That is a critical role for Public Health England. We welcome that, and working with NICE to work more closely with local authorities as well as the NHS. For instance, yesterday a big report came out, admittedly from the States, showing that the impact of being out of work in your 50s and 60s on mortality was as great as smoking; putting people out of work is an economic development and is a critical role of the council. Similarly, there is recent work on the role of isolation, particularly for the very elderly. That impact is as big as smoking and health behaviours. Public Health England is in a very good position to make the most of that linkage.
I know that the Marmot review has been working quite hard with lots of local areas to try to embed its overall high-level policy-type advice into what this can mean locally. I know the LGA is also working on this agenda. It is by no means perfect; we need to keep working hard on this, and time is of the essence. There are things in place, and I welcome Duncan’s role in particular. One of the critical roles is to make this stuff meaningful for local decision makers.
Duncan Selbie: I agree with that.
Chair: I thought you might.
Duncan Selbie: As to the pursuit and spread of knowledge and holding mirrors up at ward level there is meaning for councillors about what is going on in their community, we heard about the improvements overall in survival rates, but we also know that the gap between rich and poor has been getting wider. The reasons for this are not so much about what the NHS does, which we are familiar with in acute hospitals, but about the determinants: whether you have a job and something to do, self-esteem, a home that is not damp and where you feel safe and, crucially, whether you have someone who cares about you enough. That is why social isolation is such a killer. I hope that being able to show what is happening to your people at ward level will enrich the conversation about what we mean by health. The folk who have been hearing the messages about smoking, alcohol, diet and exercise have been acting on them and living longer and without a burden of disease for longer. For those who have not been hearing those messages, the gap has been getting wider. The way we will address those is by action at a local level, how priorities are set and how people come together. We will be seeking to share the evidence about what works, not telling people what to do but opening up possibilities.
Q4 Simon Danczuk: I want to concentrate for a moment on the workforce. The BMA said that "reforms have left the public health workforce in limbo for over two years, with many uncertain as to where they will be employed in April 2013-or even whether they will be employed at all." Is it a fair assessment by the BMA?
Dr Middleton: Absolutely. The position of many public health staff is still not determined. There is a programme through which migration to local authority public health and the NHS Commissioning Board is laid out, but there are still many people who have not been aligned as yet. There is still a due diligence process to be gone through in councils. There are posts, for instance, in policy analysis, community development and certain other areas where councillors will say, "We already do that, thank you." There is considerable risk and uncertainty for public health staff. Potentially, there will be 50 vacant directors of public health posts by April next year according to the ADPH survey. We are seeing a loss of public health staff through the recent mutually agreed resignation scheme. In my own district of Sandwell we have lost one third of our public health workforce in the last two months.
Q5 Simon Danczuk: In brief, what do you think is going to happen?
Dr Middleton: It is a period of serious risk and uncertainty. I think that we will come through it positively. The cadre of trainees in specialist positions is an excellent and outstanding bunch of people and they will graduate through the ranks, but there will be a very uncomfortable period when a large number of vacancies for directors of public health in particular is the reality.
Q6 Simon Danczuk: What are the biggest potential risks?
Dr Middleton: A real risk is that people who do not have leadership in public health do not value it and do not see what it is going to do for them.
Graham Jukes: If I may comment on a slightly different angle, what has just been commented on is the transfer of public health staff from PCTs and the existing structure into local government. That is denying the large public health workforce already out there that is not part of this process but needs to be integrated into it. Over the last nine to 12 months there has been considerable concentration on issues to do with pay and rations in the transfer process but not enough concentration on the wider public health workforce that is going to make this work far more effectively. One of the concerns raised at a meeting in Nottingham earlier this week was that there is an expectation that local authorities will take on the role of training and nurturing public health staff as they transfer in, but that is not the culture of local government. There is a culture gap around not only the existing workforce employed in local government who have public health functions but the new staff coming in, so there is a mismatch that will need to be addressed. We also need a full audit of the full public health workforce, because it is not just those who are transferring who deliver these services. From what we can see, there is no auditing going on at this moment, in fact I invite Duncan, who I only met outside, to take that on as one of the key functions-to understand what the wider public health workforce is and what training is required to support growth in the future.
Q7 Simon Danczuk: Duncan, tell us everything is going to be okay.
Duncan Selbie: I hope so. I am obviously a popular chap. My ambition and hope is that it is not this number that are public health thinkers but the entire workforce, so we have public, or the public’s, health organisations three, five or 10 years down the road. I have to recognise the personal uncertainty and, for some, trauma of the extended period of time, but it is getting to a point where certainty is starting to come into the system. About half of the workforce as we have conventionally understood it are moving into local government. For some weeks there has been an agreement in place about the transfer of staff; 152 authorities have just done a self-audit and the LGA can talk themselves about what they have discovered. But broadly it is positive. It is a period of transition and uncertainty, but it should begin to settle.
About 5,000 staff are going into local government and 5,000 are coming into Public Health England. That is all under way as well. Ninety-five per cent of those staff are coming in under what we call a lift and shift arrangement, which essentially is taking them from 70 sender organisations-forgive the language-such as the Health Protection Agency and the National Treatment Agency for Substance Misuse. They are coming into Public Health England. All of them have certainty. They would say they are not quite sure what that is going to mean for them-to whom they are accountable. Is it going to affect them day to day? Of course it is going to affect the day-to-day job, because we are trying to transform the whole. It is not just about what they used to do and then moving into a new organisation where they continue to do what they have always done, or moving from public health teams embedded in PCTs and into local government and carrying on as though nothing has ever changed. I recognise that we are going to have to invest in this. Factually, the LGA, from the work just completed, believes there will be 19 vacancies for directors of public health come April, so six out of seven will have substantive directors of public health in post. The other 19 will have acting arrangements. There will not be a situation where we go into next year and do not have somebody in charge in every part of England.
Dr Hicks: I have never seen, or been involved in, change on this scale, so I am not quite sure what one would expect. I think you would expect a degree of anxiety and discomfort. I agree with John that there is a lot of anxiety and discomfort, and it is not just about the period up to the transfer. If you look at my crew, they would accept there is a TUPE transfer process that will take them in, but they do not know what is going to happen beyond that. They are anxious about that and what it means, not so much regarding the content of their work but their terms and conditions and what will happen there, and given that no one can give them a straight answer at the moment, you can understand why.
Q8 Simon Danczuk: David, do you have anything to add?
David Buck: Not much. We get to some of the cultural issues and differences between the NHS and the way it has traditionally worked and the way the local authorities have worked, and also the role of Public Health England versus local authorities. The Government have been very explicit that they will be taking as many hands off as they can in terms of how that is organised locally, so it is not surprising there will be quite a lot of variation. The promise is that there will be more innovation and maybe variation in services and how people work and so on, but less variation in outcomes and fewer inequalities. That is the aim of the game, but through that process things are going to be very different. To reiterate, there are certain parts of the country that we know have more problems than others. London will probably be in a particular situation, but it also affects the unique characteristics of London and sharing resources across boroughs and so on, including public health staff. Part of this is the transition; part is the real concerns John talked about, but we would expect some of those because we are changing the culture of how we work. I am not really qualified to talk about individual areas as much as the other panellists.
Q9 Simon Danczuk: The UK Healthy Cities Network raises a concern about staff from the NHS moving to local government and "working in a politically-led environment", but health is nothing if not political. Should there be cause for concern there? Are there potential problems with these people moving into a political environment?
Dr Middleton: Yes of course, health is political, and arguably the reform that moves public health practitioners into the local authority should harness and make a positive out of that. I am not naïve enough to think there will not be difficulties about it. Nevertheless, the best practitioners and managers will harness the political interest to the best benefit for the public’s health. There are concerns in relation to the different cultures. Evidence base is not necessarily a political concept. Nevertheless, we all need to learn from it and increase the quality of decision making. Moving public health is not supposed to make things easier; it is supposed to make them better.
Q10 Simon Danczuk: Duncan, the Government say that one of the functions of Public Health England is to develop the public health workforce. Briefly, how do you intend to do that?
Duncan Selbie: Wherever the workforce happens to be, whether it is in Public Health England or local government or embedded in a clinical commissioning group, we have a responsibility to ensure that at undergraduate and postgraduate level and in continuing professional development for all staff, there is a framework for education and training, and research and science is brought to bear right across it. It is our job to ensure that people have access to education at every stage and learn together. Through that we will probably best address some of the cultural issues that have been raised.
Q11 Bob Blackman: One of the key areas is going to be the directors of public health; their role is vital in the whole exercise. Many of the people moving across and taking on this role will be used to making decisions and getting on with the job. But this job is a bit different, isn’t it? It is influencing people-trying to influence behaviour and local authorities. Duncan, do you have any concerns that the scope of this role might be difficult to fill in certain cases?
Duncan Selbie: We could not carry on as we were. We have a situation where we have widening gaps and experts in public health who are not as visible as they need to be; they are embedded in a health system that essentially is concerned with what goes on in hospitals. We recognise that we need to get out of that and into a system that thinks more widely about it, so it could not continue as it was. That means directors of public health and public health specialists going into local government are going to be in an environment they are not familiar with; there will be political leadership in a direct way that they are not familiar with. The opportunities will be immense, but they will be more accountable than they have ever been before. It will not be a matter of reporting what is not right; it will be about, "What are you doing to help make it right?" This is a very different ask.
Q12 Bob Blackman: People are being appointed to these jobs in an acting capacity at the moment. As time goes on there will be more people in those roles, but the key issue is whether they have the skills and capabilities now; and if not, what is being done to skill them? Simon is talking about the workforce; I am talking about the key role of the director.
Duncan Selbie: I have a particular responsibility, which I fully recognise and accept, to bring forth the leadership. We expect 133 directors of public health to move into 152 local authorities. I have got about 170 people leading on facing the regions and the national folk, including some academic input as well. With those 170 people, irrespective of who the employer is, it is my responsibility to make sure we are learning together, supporting and challenging one another and coming together regularly. This does not happen at the moment. Undoubtedly, a number of the folk already have those skills. We have some fabulous people out there.
Q13 Bob Blackman: You are happy that you have a programme in place to get everyone skilled up to do this key role.
Duncan Selbie: That is what we will have in place.
Q14 Bob Blackman: Others are itching to get in on this subject.
Graham Jukes: I had the privilege of being part of a Department of Health leadership programme, which has now sadly ceased. Most of the current DPHs have been through some sort of leadership programme. The issue for me is about where they are in the tiers of local government.
Q15 Bob Blackman: I was going to ask about that specifically. One of the concerns is that, according to the Government, they should be-I agree with this-reporting to the chief executive and not the director of adult social services, but that seems to be the structure in certain local authorities. Do you have a concern about that?
Graham Jukes: We are the victims or benefactors of localism, and it is really a question of how local authorities wish to construct their particular structures and where the DPH sits in that. It is conceivable that DPHs in some authorities will be third tier. How will that influence the public health programmes and health and wellbeing board decision making, if that is in fact the case? But there are also joint appointments. Currently, there are examples where environmental health practitioners have been appointed as directors of public health in a joint appointment process. One of our prominent members in Newham, who is a director of public health and also an environmental health practitioner, is very used to the local authority political environment and dealing with the intricacies of the debate and discussion that surround the democratic process. That is something leadership training will address. It is about how individuals will find themselves in the firmament of the structure and learn to influence those making decisions down the line, and clearly the cream will rise to the top.
Dr Hicks: I feel quite strongly about this. In 2002 I was appointed joint director of public health across the health service in a unitary authority. The role is as you describe it; it is to be an influencer, and it is too easy to focus on just a public health budget. Your aim is to get the whole of the health service budget and local government budget, plus the organisations beyond, used in a way that supports and promotes health and reduces inequalities.
To be an effective influencer you need a platform of power, and that comes in a variety of different forms: your own personal attributes; your professional and technical skills and knowledge; but you also need managerial power and an ability to deliver your home organisation. If you are employed by the council and are out and about in the town and cannot deliver your organisation, nobody is going to believe you. I do not think you can do that if you are third tier or seen as someone below it with the same status as a corporate director. If you have got corporate directors and somebody else sitting below them, they know you do not run the organisation-game over.
Dr Middleton: In moving into local authorities, they won’t know what they don’t know, and the need for the senior public health person to be at the chief officer’s table reporting to the chief executive is absolutely essential. Directors of public health need standards, resources and powers. One of the aspects of these reforms that worries me and some of my colleagues is the notion of assurance-that we will somehow float over the whole system and say it is all okay. Is it a warm glow you feel when the hospital tells you it is doing the right thing, or is it a critical inspection of what is going on, be it in infection control, screening or any of the other areas? To me, it feels that directors of public health need to have both the resource and the power to deliver those.
As to standards, councils are used to working in a peer-led environment and sector-led improvement. As a faculty of public health, we are keen to support that process. The whole system needs to work at a sufficient level. If I as a local authority officer find that the neighbours are not doing as well as they need to on TB, genitourinary medicine or drug control, those problems are my problems too. If I have a wonderful town planning service that does safe walking and cycling and those routes stop at the border, we will not get the best for public health, so we need standards across authorities.
Q16 Bob Blackman: You have mentioned London. I am aware that different authorities that are not adjacent are appointing joint directors with joint teams across very different geographical areas. Do you have any concerns about that type of arrangement, where they are sharing resources and potentially dissipating the effort within those boroughs?
Graham Jukes: I do have concerns about geographical issues to do with how these appointments are being arranged, because that will lead not only to inefficiencies but different types of issues in relation to the policy of adjacent and adjoining local authorities. That needs to be managed in the right way.
Q17 Bob Blackman: So if two adjacent authorities do this, it would not be an issue.
Graham Jukes: It would not be a problem.
Q18 Bob Blackman: But if they are doing it with a wide difference geographically, it would be a problem.
Graham Jukes: Yes, it would be.
Duncan Selbie: When we are thinking about the future, we must not have a rosy picture about our past. We have not had 152 brilliant leaders in public health with influence and access and getting it all done. That is a big part of why we are making these changes. I am much more concerned about the director of public health being on the top team rather than to whom he is accountable. In statute they are chief officers and are accountable to the chief executive; they have direct unfettered access to members. It is about how they have influence across everything.
To revert to London, I am seeing them tomorrow afternoon. If we had been seeing each other on Friday, I could have given you a very clear view. It is precisely about whether we are getting this right, not just on day one but what happens subsequently. Not just in the last year but over a number of years there has been history about the capability of public health in London. My issue is less about adjacency and more that they share all of their functions. If two boroughs adjacent to each other share all of the corporate functions, that is fine. There are choices. We have been very clear that we are not telling local government how it should organise, but it needs to be infiltrating everything. If you have one borough doing everything separately from another but sharing a single director of public health, I would be more concerned. Does that make sense?
Bob Blackman: Yes, absolutely.
Q19 James Morris: To follow up Bob’s point, I represent part of the Black Country and Dr Middleton will know some of that area well. I know there have been discussions between Sandwell metropolitan borough and Dudley about sharing a public health director. Surely, there is a strong rationale in an area like the Black Country for a director of public health who may straddle all four of the local authorities in that area, because one of the advantages is that a strategic needs assessment of the health of the Black Country, given its geographical composition and population make-up, would make a huge amount of sense, wouldn’t it?
Dr Middleton: Should I answer that, and do I declare an interest and leave the room? There was a discussion of a Black Country DPH and of a shared DPH. There was a realisation that even a shared DPH would potentially be an impossible job, with two health and wellbeing boards, two scrutiny committees, two council management teams and three or four clinical commissioning groups extending into Birmingham, because of Sandwell’s relations with Birmingham. In the end it was a practical consideration that it could not be done. That may be a consideration for other local areas where they do consider that. For instance, in Greater Manchester they have all committed to their separate directors of public health, but then they commit to sharing other functions like information, intelligence, health protection and so on. Having that leader and senior position for each council is certainly what I think should happen, but I am conscious that for some localities and some parts of London that is not simply practical, so there has to be a local discussion on that.
Graham Jukes: We are on a journey; it does not start on 1 April, so we are moving forward. One of the big challenges will be to create cohesive plans that address inequalities in health in local communities, which are no respecters of boundaries. There are boundaries that go through various things. The challenge for DPHs, health and wellbeing boards and local councils is to marshal their resources, understand the problems of their respective communities and try to find strategies to deal with them. That is a significant challenge and one that I think the people chosen for this job will be up for. It is up to Public Health England and organisations like my own and others sitting round this table to support that process.
Q20 Simon Danczuk: Duncan, I am worried about frontline health protection, whether it is an E. coli outbreak as happened in Germany or a Legionnaires’ outbreak as happened in Edinburgh. I am not the only person who is worried. Concerns have been voiced about considerable and unacceptable uncertainty about the health protection function and that arrangements are unclear, are denuded of resources and filled with risk. That is what reputable organisations are saying about it. How do you respond to that?
Duncan Selbie: I have to recognise what people are saying. Let me tell you what is happening. All of the Health Protection Agency is moving entirely, as it is now, into Public Health England, so the experience of people at local level will not be disturbed by these changes. Directors of public health, with everything that has been said this afternoon, are asking what it is going to mean and who will be doing what. The practical experience of outbreaks, whether it is measles, food poisoning or something going wrong on a petting farm, is that 90% of these incidents are handled locally, and always will be. Public Health England from now through to April and beyond will be the responsible people for making sure that the resources, when something escalates, are there, so it is all about people and relationships at local level. I will do everything I possibly can to make sure that people know whom to talk to from day one and we simply do not have that risk emerging.
Q21 Simon Danczuk: On 2 April there is absolutely nothing to worry about. You are saying to me and others who have raised concerns that if something goes wrong you will be ready and it will be dealt with.
Duncan Selbie: We will be ready.
Graham Jukes: These controls are already in place. Environmental health officers in local authorities deal with E. coli, Legionnaires’ disease, problems with public and private water supplies and outbreaks. They rely upon the support of the HPA, now Public Health England. There is concern about the shape of local government in terms of the cuts it is having to bear and the austerity measures, but largely it will not be as a result of the changes that are taking place; it will be about how local authorities can respond to those challenges and what responses they can get from Public Health England and others as we move into the new structure.
Q22 Simon Danczuk: Nick, you have an interest in the NHS Commissioning Board in terms of public health. Are you also comfortable with all the contingency arrangements?
Dr Hicks: I can speak as the DPH in Milton Keynes rather than for the commissioning board. My experience on the ground is that we already have good relationships with the environmental health personnel and other colleagues in the council, and we have excellent support from the Health Protection Agency. There is new clear guidance about how the system should work in future, and already the directors of public health, local authorities and the Health Protection Agency have well developed conversations and plans. I believe the personal relationships will stay very similar for now. We have one detail that is a geographical change; we have to work out how we relate to the Thames Valley and a different Public Health England centre, but I have no doubt that that work is manageable and is being managed. I do not share the anxiety that has been reflected to you.
Q23 Simon Danczuk: John, are you comfortable that we have cross-boundary working across local authorities at sub-regional level?
Dr Middleton: I have every confidence in what Duncan Selbie describes from Public Health England, and very little confidence in what I have heard described in relation to screening, immunisation and emergency planning around the NHS Commissioning Board. I come back to the word "assurance". The staff we have trained and developed in Sandwell who are involved in screening and immunisation on a daily basis are destined for Public Health England and to be seconded to the National Health Service Commissioning Board and managed by heads of public health commissioning with no qualification in public health necessarily. You would not invent that system if it was not for the extraordinary difficulties that the health reforms put us in.
As to health protection, we need to emphasise that there is a whole preventive infrastructure in place in local authorities, as Graham described, but there has been a very successful infrastructure for infection control in primary care trusts. The district infection prevention control officers have an excellent story of reducing healthcare-acquired infection. These are not things where the Health Protection Agency historically has done a great deal of hands-on work. These are ecological problems. If pharmacists prescribe loperamide, GPs prescribe antibiotics, care homes do not clean their mattresses more than once every 15 years and hospitals do not record the data on clostridium difficile, potentially these send infections spiralling around our communities, and we need to be able to see that preventive work carried on in local authorities.
Q24 Simon Danczuk: I was reassured until you spoke.
Duncan Selbie: John conflated two things: screening and immunisation is a separate matter, which we can touch on if you wish. You were asking about health protection. My categoric assurance to the Committee is that there is no cause for anxiety or concern about managing this in a safe way. In the Health Protection Agency we have a world-class organisation; it is rated internationally, and we are very good at it. It is coming into Public Health England in its entirety. We have embedded public health teams in every local authority, and we have been very careful about getting guidance out. That helps, but what matters is relationships. Those conversations will be going on, and watch what happens on 2 April. It is not going to be any different from 31 March. There is an issue about screening and immunisation. I agree that we would not have invented this, but it is my job with others to make sure that we have a safe transit, but do not conflate the two things; they are not the same.
Q25 Mark Pawsey: I want to ask about funding and ring-fencing, but I start off with health inequalities. The Advisory Committee on Resource Allocation has set out its interim proposals. Mr Jukes, your institute is very critical and has said that, "For a local authority with high levels of deprivation and poverty, a formula which does not explicitly distribute the grant funding by reference to such matters will see its ability to address health inequalities decline over time." You are critical of the funding method, but you also go on to say that "the forecast £2.2 billion available for local authorities is insufficient by 50% ... and public health services ... are in danger of being set up to fail". You are critical of both the amount of money being allocated and way it is being distributed. How would you change things if you were given a blank piece of paper?
Graham Jukes: I would provide more money.
Q26 Mark Pawsey: That is very easy.
Graham Jukes: It is a very easy answer. If I may, I will just sidestep that question with a broader one. The money we are talking about here is about the transfer of the functions. At our conference on Monday, the Minister was very kind to say that the funding base would be provided very soon, so we are expecting that certainly by the end of this month, if not early next month.
Q27 Mark Pawsey: So is the figure I have given wrong?
Graham Jukes: We do not know what the figure is. At the moment those are estimates. The Minister will be publishing those figures, and once we know what they are, we can comment further.
Q28 Mark Pawsey: Whatever it is, it is too small, as far as you are concerned?
Graham Jukes: If it is of that order, it will be. But the broader issue I want to touch upon is that of local government. I made a comment earlier about the preparedness and readiness of local government not only to receive these functions but carry on doing their normal work. Within the last three years local government has lost 30% of its resources. In environmental health terms that is about 8% of the resource base. There is concern that further spending reviews will add to that burden, which means that coming into local government is a function that needs resource and investment and an existing workforce and structures that are being diminished as we speak. Different structures and systems are emerging. We have a bigger problem here, which is not just about the amount of money but where we put our investment and focus on workforce planning, and how we invest in that for the future. It is a bit trite to say it is not enough, because it will never be enough. The real question we ought to be asking is what we need to do with that money, how it will be effectively used and how we will tackle that.
Q29 Mark Pawsey: What are the views of the others on dealing with inequalities?
David Buck: When we looked at this issue, there were three or four core things. One is: is the amount of money right? You would expect the Department to have worked out what amount of money is required, as opposed to counting how much PCTs have spent in the past. I am not sure whether or not the Department has done that, but that is critical. A formula, even if it is perfect, depending on your views on the formula itself, will redistribute only a given pot; it will not tell you how much you are supposed to spend. It is a real shame that the Department does not seem to have done that work. If it has, it has not made it public. You are quite right that, as far as we know, possibly £2.2 billion will go into local authorities. The rest of the pot, about £3 billion, is still the domain of the NHS and the NHS Commissioning Board in particular. We have not talked that much about the NHS Commissioning Board today, but clearly it has a massively significant role, particularly in screening and immunisation and so on. The relationship between Duncan and the commissioning board is a critical one. None the less, there is a question about the amount. I do not know whether or not it is right, and it is hard to say. One would hope the Department would have taken view on that and made that public as it was doing this work, but it has not as far as I am aware.
As to the formula itself, if you are going to choose a formula, the standardised mortality ratio under 75 is, I am sure, admirably simple compared with the NHS and local government formula. That has a lot going for it. There are real issues about that in the sense that a standardised mortality ratio under 75 probably tells you a lot about the experience of people in a local authority area over time who are now dying before 75. It tells you a lot about past problems in local authorities, but there is a real question about whether it tells you about the current problems in local authorities, particularly in areas with younger populations and behaviour problems, behaviour change, unhealthy behaviours and so on. There is a question about the variable itself. It may need to be supplemented by others. Others have suggested deprivation or some healthy behaviour-type indicators, which we now have through the public health outcomes framework.
The additional question is whether a formula approach is the right way to go. Our thinking as it has developed is that, if you have a given pot of money and you give local authority mandatory things to deliver, you should make an attempt to look at how much it costs to deliver those services from a bottom-up perspective. If you have a defined standard and an equitable standard, going to your point about inequalities, and money is left over, a formula may be a good approach to distributing what is left. SMR is a good stab at that, but there are cases for changing it. Because of the mandatory services, we should be after a formula plus, not simply a formula, and how you allocate resources should be driven by the system you have designed, and similarly for the ring-fencing question.
Q30 Mark Pawsey: I will come back to ring-fencing in a minute, but I would first like the views of the other panel members on inequalities.
Dr Middleton: I was a party to discussions about deprivation versus the use of mortality for the formula, and therefore I hold up my hand as part of the responsibility for that. All of the evidence of Marmot suggests that mortality is strongly related to deprivation. You could choose a deprivation measure or take the mortality measure. The problem is that, when you look at what is in the ring-fenced budget, it is not about premature mortality; it is about genitourinary medicine services, school nursing and drugs and alcohol services. We have used one formula potentially to describe a totally different set of problems and answers that we need.
Q31 Mark Pawsey: But does the formula deal with inequalities or exacerbate them in your view?
Dr Middleton: At this point it is the simplest and most straightforward answer that we can have to the question of inequalities as a pragmatic solution.
Dr Hicks: My answer is similar to John’s. It goes back to what your definition of "public health" is. At the beginning we talked about the public health budget for a community. My aim as a director of public health is to get the totality of that money being spent, so in practice I am more interested in the total allocation in the community rather than the tiny percentage of that that is called the public health budget. That budget is used for specific services. If I look at my local authority, the three biggest items are sexual health services, substance misuse services and health checks. They are all good things to do, but they are a small subset of public health and not the major mechanisms to tackle inequalities. I would like the total formula coming into my population across the health service, police, local authority grants and all the rest of it to reflect the needs of my community. I would agree with the two other speakers that lots of these measures are highly correlated, so why not pick the simplest? The standardised mortality ratio for people under 75 seems a nice simple method and avoids lots of other complications.
Q32 Mark Pawsey: I want to come back to the services. Mr Selbie, what is your view of inequalities?
Duncan Selbie: I want all the money everyone has got for this, but I have a megalomaniac’s view of it and want to own all of it. I want to comment on why we are in the position of not knowing what we have been spending. It reflects that all of us have conflated health and the NHS for so many years. I want to return to that. It is important that we do not see the NHS as about health; it is a contribution, but it is all the other things we have talked about that matter. If you ask the Department of Health what is being spent in A&E or in aortic aneurism surgery, or something going on in a hospital, they will be able to tell you precisely. If you asked them what they had been spending on public health, they did not know because we did not ask. The first thing we had to do was establish the base line. What have people been spending beyond the mandatory services? It is not a satisfactory starting position, because we are not addressing what you should be spending, which is the formula, but what you are spending. It was the first time we had ever gone through this exercise. We have to make sure that we are covering what is currently being spent-that is what the focus has been on-concurrently with the examination of a formula. The first thing we have committed to is that local government will not have less than is currently being spent, and that commitment is for next year.
Q33 Mark Pawsey: Are you satisfied that is being done? Mr Jukes is not.
Duncan Selbie: We have been out several times. This has been an iterative process, and it is not yet complete, but we are committed to ensuring-I hope I have been very clear about it-that what has been spent by PCTs on public health will be transferring into local government intact. Then there is a conversation about growth, and that will be announced when the Secretary of State is ready. It will be some time before Christmas.
Q34 Mark Pawsey: This money is to be ring-fenced. How does that sit with the principles of localism? Mr Buck has lots of confidence in local authorities because he tells us they engage so much better and, on that basis, they should be able to spend money better, but we are ring-fencing it and determining what should be done with it. How does that sit with localism?
Duncan Selbie: I want more money to go into this, because the prevention agenda is where we will get in early, and it will save the country. It is an economic decision as much as anything else. This is the starting position; it is not the next conversation, or even the last one. What we are saying to local government is that we will make sure it will get what is currently being spent by the NHS. It will not get less than that. We will see what we can do about growth, and there is a conversation to be had about the pace of change. We have said there are five matters that are mandated, including the health check Nick talked about; the sexual health service; the provision of advice to CCG. We have not mandated drug services, for example, and about a quarter of the funding going into local government will be for drug services. You cannot say the mandated services are everything that has been spent on the public; it is part of it.
Q35 Mark Pawsey: Mr Buck, are you happy to see this level of mandated services, or do you have more confidence in councils to react to their own individual circumstances?
David Buck: I have a personal view, which is probably not the Fund’s view.
Q36 Mark Pawsey: Give both of them.
David Buck: Maybe it is the Fund’s view; I am not sure. I completely accept Duncan’s point that we have never measured public health spend before. It is a very difficult thing to do. The fact that PCTs were just left to spend whatever they wanted on public health is a bad thing and we are moving to a better position.
The other positive thing to say about inequalities is that, as far as I understand, the formula will be based on very small area estimates of inequality rather than local authority-wide. For instance, we know that Westminster overall is a very wealthy authority but it has very small pockets of deprivation. That did not really get reflected in its allocations under the old system and it will do under the new one. That is a positive move for inequalities. PCTs spent basically what they wanted. Some of the forward-thinking ones invested a lot in public health; some of them did not invest very much at all. We can have a debate about the formula itself and whether it is formula plus baseline or whatever, but the critical thing is the transition to what the formula implies. We know that is very different from where the money is at the moment, so the transition to the formula is going to be the critical issue. Because there is likely to be very little growth in public health budgets, it is going to be hard to move to where the money should be from a fair basis, which is England-level need, versus possibly taking money out of, or certainly not giving extra money to, authorities that have probably invested more in the past. There is a real issue about transition. Either you are unfair to local authorities who have put in a lot of money in the past or unfair to the need as a whole, and that is a tricky thing for the DH, Public Health England and the Minister to decide.
Duncan Selbie: Which is why it is taking us some time.
Dr Hicks: You are not going to tackle inequalities with £2 billion nationally; it is the totality that makes a difference. Over the last decade there have been examples of where things have improved. You can measure inequalities in different ways. You can measure either a slope or the gap between two different bits of a population. An example of where things have gone well is that a national target was set for the reduction of inequalities in infant mortality. That was supported by concerted action nationally. There were public service agreements in which every department of state bent its actions to that, supplemented by freedom and incentivisation of local authorities through local public service agreements. I do not think it is widely understood. That target was hit two years early. Everyone said it could not be done, and combined action nationally, co-ordinated with appropriate local incentives, produced a fantastic result. We got infant mortality down to the lowest levels we had ever seen and the inequality reduced, and the national target was hit two years early. We do have examples of how, by bending the totality of resources, not just this tiny sliver labelled public health, we can do something that is genuinely wonderful.
Q37 Mark Pawsey: Dr Hicks, I think it was you who spoke about the difference between preventative work and the fact that might get squeezed because of the amount of demand-led services, such as perhaps sexual health. How do we deal with that tension? Where should the priorities be, or should we leave that to local authorities?
Dr Hicks: This is now personal opinion. I could not conceive of not providing comprehensive health services that are both preventative in nature but also respond to demand. Personally, I would like to see the same for substance misuse services too. There are difficult trade-offs to be made against other preventative areas. I do not think there is a single right answer. Personally, I would make sure there are services that need to be provided, just as you need to provide education services, and hold people to account for providing those services but still allow a lot of local discretion for people to design them. I like the idea of holding people to account for outcomes. The strength with which you hold people to account is also important.
Q38 Mark Pawsey: Has the Advisory Committee on Resource Allocation got this tension right? Does it need to go back to the drawing board, or are you broadly happy with where it has set things?
Duncan Selbie: It has yet to report, so this is the stuff of the next few weeks. Can I just comment briefly on Nick’s point? One of the things we could do so much better, to go back to the earlier point about the spread of knowledge, is understand how people are approaching this in different parts of the country and with what impact; that is, making sure others know about those who are able to do better with this. It is not just about how much we are spending but how well we are spending it. If we take sexual health services and the way these are managed and distributed and who is providing them, there are many different ways of doing it. Some are more efficient and some cost less and some cost more. We will be able to make sure people are aware of what works at what cost and what their options might be. It is less about whether or not they have it and more about how they go about ensuring it.
Dr Middleton: In response to your question about the overall allocation, if we simply reallocate the pot we have, we will disadvantage those who have spent more against their level of need now. As we have with health service allocations in the past, my understanding is that we are looking at the formula to move people or not, as the case may be. There are other real problems with the ring-fenced budget not specific to the ring-fence: the level of investment we are talking about, £2.2 billion, and the risks around GU medicine, which is growing by 3% or 4% a year. For my PCT an extra £400,000 a year was nothing out of £500 million, but my local authority is extremely concerned about £400,000 out of £20 million. This is an area of risk that local authorities are very concerned about. In Westminster two-thirds of the budget goes on the GU medicine service, and they could spend all of the ring-fence in a very short space of time with those increases in activity.
Q39 Bill Esterson: John, I was going to ask about the impact on local authorities of this additional service and their ability to manage it. If you look at the LGA graph of doom, everything excluding social care and waste management by 2020 will have lost 90% plus of its moneys. If what you have just said is right, there will be pressures on the remaining 10% to fulfil the public health function. Social care is a demand-led service, which already puts that under pressure. There are additional demand-led services. Can local authorities cope with this?
Dr Middleton: I raise it because I see it as a major risk. Whether or not, as we have had in the context of NHS investment, you can have some kind of shared risk programme for that, clearly it is something that adds to demand-led services. The additional complication for local authorities, which also impact on providers, is moving back to resident-based payments versus responsible population base. I do not think our providers are geared to that, so either there will be a shortage of service or people with invoices that they are trying to get paid.
Dr Hicks: The straight answer is that I do not know whether or not they can cope, but I hope there are other benefits of public health expertise going into local government. For example, I like to think that we have a scientific as well as political approach to our work. There are things we could help about improving efficiency and value for money that comes from social care, for example. I see very little data about the effectiveness of individual interventions. I do not know whether intervening one step lower prevents three people going to a more expensive and severe level. I hope we can work with colleagues in social services and others to apply those sorts of approaches that have been relatively familiar as a process within health services.
Graham Jukes: There has to be investment in getting ahead of the curve. It was Derek Wanless who coined that phrase. The problem is that the unaffordability of the current NHS system of services and transfer of public health into local government gives an opportunity for us to start to address some of the preventative care issues from a housing and whole-place perspective. I certainly do not think the existing amount of finance will be enough to get us to that place. I want to look into the future once we are past the recessionary process we are currently in and build a system within local government that can respond to some of the more inherent issues to do with people’s health. We have to play a long game here; we have to build and invest in structures that will help us address inequalities in health over a much longer period of time.
David Buck: I do not think we should fool ourselves that preventative public health is going to save vast amounts of money very quickly. Public health certainly can be cost-effective and in some circumstances save money, but most of public health-I would imagine other panellists would agree-is about delaying costs. We will all get old and pass away from something. One of the successes of the NHS is that we are now seeing a much older population that is very frail, which then leads to high costs later in life. It is almost another epidemiological transition, with increasing rates of dementia and so on. That is part of the success of the NHS as a treatment organisation and, in the past, in terms of public health intervention. We should not sell public health as saving the NHS, because I do not think it necessarily will, but it is a good thing in and of itself and we should do those public health things cost-effectively.
To go back to ring-fences-I apologise that I did not answer your question-our view is that they are more appropriate when what you have to deliver is very specific. If you have to deliver a specific service to a particular standard, you know what you are delivering. You are already interested in delivering processes, so doing things to people rather than outcomes per se, and you have a lot of clarity about what needs to be done. You are not particularly concerned about innovation. If there is a ring-fenced budget, you can add it up and know how much to spend on it; it is an obvious service that you have to deliver. Ring-fences in our opinion are less appropriate when you expect and want more localism and innovation, so you want variation. It is the outcomes you are interested in that are really important, not how you get to them, and you expect local areas to deliver them in the way that is fit for them with no specific configuration of services. You are not specifying that, but also critically you have strong accountability to the funder, which in this case in this transfer is the Secretary of State for Health’s budget.
As to where we are with the current system, we would argue that you should design your system and then decide whether you need a ring-fence, rather than decide to have a ring-fence and design the system. Clearly, there are elements in current public health service where we are moving to that latter system. These reforms are the direction of travel, but we are not there yet, which means there is some debate about ring-fencing. We may be moving to letting go of ring-fencing, but clearly there are some public health services, particularly health protection, which are very much specific and mandated; they have to be there. You cannot slice away at the edges, because if you get rid of the edges the whole thing collapses. On the question of ring-fencing, you need to design the system first and then decide to what extent you need a ring-fence, not the other way round.
Q40 John Stevenson: If in a perfect world you get your funding formula right, your ring-fenced funding and public health directors in place, to go back to one of our earlier questions about the political element, is there not a danger, particularly in the present environment, that there will be tremendous pressure coming from local politicians, probably chief executives and so on, to allocate the funds in that ring-fenced budget in a slightly different way so that it is more in tune with what the politicians want than necessarily the public health director wants?
David Buck: I am sure there is. We have not talked too much about the outcomes framework today, but accountability for them, both locally and nationally, is critical. Duncan talked a little about accountability as well as focusing on understanding and the incredible science around public health. It is also critical to get the accountabilities and then the outcomes right. From our perspective, we are not as concerned about how you get to the outcomes as long as you get there and you have accountability for them. That is an easy thing to say and a hard thing to do.
Duncan Selbie: The point and purpose is political leadership at a local level working out what matters and having the resource to address it. I agree about the ring-fence and where we have come from. It was a concern that at the initial stages we needed to get some protection of the public health moneys, but the point is to get to a stage later, and soon, where that would not be so very necessary. We have matured again.
Dr Hicks: All the way through we have had the comment that everyone has recognised the opportunity and how fantastic it will be when local government has put health right at the centre of what it does. I am sure that will happen in lots of places. It is also worth asking the question: what if there were places where that did not happen and they did not see health as the most important thing in life? If one is honest and stands back to look at the history of public health, many of the biggest advances have come by bloody-minded people challenging strong vested interests in their local communities, whether it be the Factories Act or slum clearance. What if you had a community where the main source of income was a tobacco factory, and the health and wellbeing board came up with fantastic tobacco control plans? One can imagine the scenario where people are voted in by those whose livelihoods depend on tobacco sales. In that community perhaps the money was disappearing and substance misuse services disappeared. It is worth asking ourselves: what is the protection for people in those sorts of areas? Much as I would like to think I could win every political battle, in reality I know that is absolutely not the case. There will be things on which I and perhaps others feel strongly where in the politics we lose the battle. As well as being rosy and very optimistic about the opportunities, there will be places where the opportunities are not realised and things go in the opposite direction. We do need to ask ourselves how we intervene and hold people to account in those circumstances.
Dr Middleton: For many years in the NHS I believed that we were arguing our case in each round of development and prevention would win out in the end, and I did not want a ring-fenced budget for it. In about the last year in the NHS I became convinced that ring-fencing was essential. The justification for our move to the local authority was the lack of success of public health being recognised in the NHS. We need a ring-fenced budget protected for the foreseeable future, perhaps an expanded one, and in that great future with local authorities recognising the value of health, we will have a much bigger ring-fence created by local authorities.
Q41 John Stevenson: Moving on to the health and wellbeing boards, they have been widely welcomed, but there is concern that they do not necessarily remove the barriers to joined-up care; some boards are moving at a faster pace than others and some will get left behind, and obviously some will be very successful. The danger is that the initial enthusiasm for them will wane as time passes and realities of life kick in. How are you going to deal with that?
Graham Jukes: As to success so far, some research has recently been carried out, which we released on Monday, indicating that most health and wellbeing boards were structurally being set up reasonably well. The issue is about how health and wellbeing boards co-ordinate with their respective councils at the top tier of local government and how they are engaging with district councils below that. We are starting to see parallel structures being created with local health and wellbeing boards and local JSNAs. They are starting to tease out the issues within local government. In terms of the structure, shape and direction of health and wellbeing boards, we are seeing those established well. The statistic that comes to mind is that 95% of all local authorities have those well in place as shadow mechanisms. The challenge is how those health and wellbeing boards are properly informed by their constituent parts, and how that cascades down into policy and strategy delivery. As colleagues said, it is about the outcome at the end of the day. If health and wellbeing boards are not being properly advised-from a professional and parochial perspective, environmental health practitioners are not represented on health and wellbeing boards because they are largely at district council level-there is lack of influence there. Putting that professional parochialism to one side, I see health and wellbeing boards being set up reasonably well at this moment.
Dr Middleton: For once, I can be completely upbeat about something. Health and wellbeing boards are being embraced. They have the benefit of having some continuity with the health and wellbeing boards that have been in place since 2007 in many cases. They also have the benefit of being the least prescribed part of the Health and Social Care Act. There is a lot of scope for local determination of what they look like. They also have the benefit that they are the glue; they are the central point. They are the only coherent part for many local authorities, and they are the engine room through which health strategy can be delivered. It is a body we need to support and develop.
In Sandwell it is chaired by the leader of the council, and that top-level seriousness that is going into the health and wellbeing board is extremely crucial. We have seen it at least as a meeting of commissioners; it is not yet a commissioning body, but we will need to pool more budgets potentially, not fewer. We will certainly need to share our parallel investments in alcohol, drugs and so on, and it is a forum we want to support.
Q42 John Stevenson: Clearly, you are an enthusiast and see them as a positive thing, but is there a danger that some councils will take more interest in them than others, and therefore you could end up with a two-tier system?
Dr Middleton: It is. As I said earlier, there needs to be a minimum expectation across the board about what is acceptable and necessary to deliver a safe public health system. There are real concerns and tensions in county councils and districts. There will be different solutions in different councils, so it will not be one size fits all, but there has to be something and that is what we need to monitor.
Q43 John Stevenson: Does a two-tier system concern you at all?
Duncan Selbie: Yes. I am sure I should reciprocate and say something really miserable, but I do not feel able to. That is the essential message. When we talk about real life, there will be differences around the nation and it will wax and wane a bit, but we are all seeing health and wellbeing boards as the front line where these big engines come together-the commissioning board and local government responsibilities-to make sure we have got one set of priorities and not competing ones. We have to believe this is going to be better than anything we have had before, but of course there will be differences in commitment and in just how effective these organisations are.
David Buck: I will be positive about this as well. We have seen a lot of enthusiasm on the boards we have helped to develop, both on public health and broader issues as well. They are essentially all natural experiments, so we will see a lot of variation in terms of the structure, the number of people on them and, therefore, the decisions they take, if they do end up taking decisions. The ones we are working with are starting to think, "Are we really commissioners, doers, checkers or inspirers? Is it our role to set the long-term vision? Is it our role to do some short-term fixes year on year?" The answer is yes to all of those in certain parts of the country. We have to keep our eye on how that is going, and we intend to do another survey soon about that. We will see a lot of variation around services. The critical thing is that that does not translate into a lot of negative variation around outcomes. That is where localism and accountability for outcomes come together. We probably need to do a bit more thinking about that. The concern is that outcomes start to drift. Duncan and the Government have been very clear that Public Health England is not a performance manager in the way the Department of Health used to be, and sector-led improvement is the way to go, but I do have some concerns about how we support the real tail of possible poor performance. That may come about because of greater localism. That is an obvious risk of localism, but there are many benefits as well.
We are generally very positive about health and wellbeing boards. We have to be careful about expecting too much of them too early. Although we have been talking about them for ages, they are still not there. When the money starts to hit and they take those really big decisions, we have to think about how it is working. We have seen some great health and wellbeing boards with a shared vision locally, which is fantastic; they are starting to get their plans and leadership right. It brings together GPs and councillors, which is critical, but some of them are not thinking about the money. They agree everything and so on, but they have not put the resources alongside it. I am not sure how representative that is, but that is the thing on which they have to focus next, and we have not talked about the wider context.
Q44 James Morris: I want to pick up one point about the health and wellbeing boards. The King’s Fund raised a concern. If they are to be a commissioning body, will that detract from integration of care? Do you have any views on whether that is a danger with health and wellbeing boards?
Dr Hicks: If they are a commissioning body, that would promote the integration of care. If you have all the commissioners in the community sitting together round one table and they have decided to commission something together in a common policy and spend their budget in a coordinated way-John mentioned the pooling of budgets-particularly if they ask for a set of outcomes rather than processes, the way the providers respond would have to be more integrated, for example on the basis that they are all being held to account to deliver a set of outcomes for the frail elderly.
Q45 James Morris: Mr Buck, you raised the issue that, because of the potential exclusion of providers from health and wellbeing boards, this might create some problems.
David Buck: What is right locally is right locally, but about one-quarter of health and wellbeing boards according to my survey earlier in the year had providers on the board. Other health and wellbeing boards will deal with it in different ways. Some have provider forums, for instance, as a way of separating the commissioning from provision and the potential conflicts of interest. There is variation. Personally, it is good to get everyone around the table, but obviously there are some conflicts, which I do not think have been necessarily sorted out.
The other issue about health and wellbeing boards that we have not touched on very much is the role of the NHS Commissioning Board. That is the big player with the big money around the table. We have had some concerns in our survey that people were not convinced they would be able to influence the NHS Commissioning Board locally around health and wellbeing. That is a real pressure. For me, that takes us back to the issue of accountability. Going back to the history of the NHS, CCGs are looking very closely at the commissioning board in terms of whom they follow. We have the commissioning outcomes framework between the NHS outcomes framework and the CCGs. It is very strong accountability up to the NHS Commissioning Board. The public health outcomes framework is explicitly different from that; it is much more about transparency. There is a concern that health and wellbeing boards will not really get the commissioning board input into local decisions.
Q46 James Morris: Mr Selbie, you wanted to make a final point.
Duncan Selbie: I was going to draw a distinction between the commissioning of integrated care and how we involve providers, not just statutory ones but the voluntary sector, in the design. When we talk about commissioning, what really matters is that you involve the provider in all its different forms in the design of what you are seeking to commission and separate that from the commissioning, so you have dealt with the conflict. You do not deal with the conflict by excluding them; you get them involved in the design.
Q47 Chair: That leads on to the final point. The NHS Confederation has been concerned about the eight different commissioners of child health services. There are many views around the table at the health and wellbeing boards. If you then bring in providers, schools and police and crime commissioners, will you not get to a situation where nobody is going to make a decision about anything? They will just sit down and talk for a couple of hours.
Duncan Selbie: That is the point. If you say you cannot be involved because you might be conflicted, it means that 90% of the folk cannot be in the room. I am drawing a distinction in terms of how you involve folk in the design. What does "good" look like? Then it is a matter of what the subsequent commissioning looks like.
Q48 Chair: But you have eight different organisations involved in commissioning child health services.
Duncan Selbie: You are picking a particular area.
Dr Hicks: There is a lot of anxiety about that specific issue. I was part of the Children and Young People’s Health Outcomes Forum. There are people talking about ways in which that can be overcome. For example, most places have either a children’s trust or the remnants of one as some sort of children’s partnership. I know there are certainly places where people think that group, which brings together interested parties and children, can have a relationship with the health and wellbeing board as a subcommittee. Some people are suggesting delegating to that body the production of the joint strategic needs assessment and a joint health and wellbeing strategy for children. If you have all your children round that area, including representation from the commissioning board, CCGs and local authorities, you are in a very strong position. You have one needs assessment, one plan and all the commissioners. If they present their money, effectively you have a coordinated budget. All you need to do is apply to the commissioner because you now have an integrated service by bringing everyone together. If all people are conscious of that risk, there are ways it can be mitigated locally.
Dr Middleton: An additional positive is that the fact commissioning for drug and alcohol misuse, vulnerable young people and so on is coming into the local authority on the back of public health is an opportunity to bring the safeguarding of children closer to a public health agenda. In dealing with issues of domestic violence, new migrant populations and all these things there is a chance of a more coordinated approach by local authorities, but the overall issue of eight separate commissioners is a problem. The NHS Commissioning Board doing the nought to fives until 2015-16 suggests that we do not trust local authorities with that kind of commissioning, and that is a mistake.
Chair: There are issues we will want to come back to. One of the things we have heard about today is the real opportunity for some good innovation and progress, and the concern that probably we will have a problem with those authorities that do not really get it. That may be something we have to follow up in due course. Thank you very much indeed to all of you for coming to give evidence to us.