Oral evidence: Public Health post-2013—Structures, Organisation, Funding and Delivery, HC 140Tuesday 7 June 2016
Oral evidence, 7 June 2016.
Witnesses
Jane Ellison MP, Parliamentary Under-Secretary of State for Public Health, Department of Health, Simon Stevens, Chief Executive of NHS England, and Duncan Selbie, Chief Executive, Public Health England, gave evidence.
Chair
Good morning and thank you for coming to our second panel. Could I start by asking you to introduce yourselves to those following from outside the room, starting with you, Minister?
Jane Ellison
I am Jane Ellison, public health Minister since October 2013.
Simon Stevens
I am Simon Stevens, chief executive of NHS England.
Duncan Selbie
I am Duncan Selbie, chief executive of Public Health England.
Chair
Thank you. Helen is going to start the questioning.
Helen Whately
Thank you very much. The Five Year Forward View called for a radical upgrade in prevention and support for wider public health measures. Coming to you, Simon Stevens, first, what assumption was made in the Five Year Forward View on the investment in public health that was required and the NHS demand that would be avoided as a result?
Simon Stevens
Possibly the last time we were together we set out the detail around the demand management assumptions in the Five Year Forward View, and a part of that, as you rightly say, comes from a recommendation in the forward view that we should be upping our game on prevention. That includes many of the things that no doubt we will talk about this morning, but with a particular focus on obesity, recognising that we are now spending more on obesity‑related conditions in this country than we are on the police or the fire service, and a good place to start would be childhood obesity. The sugar tax in the budget is a key building block of that, but there is a lot more that needs to be done. So when the Government bring forward the childhood obesity strategy shortly—one hopes—there are a range of things that we want to see in there as well.
Helen Whately
Could you possibly be a bit more specific, though, in response to my question on the investment that was envisaged and included in the model, and then the activity or value of activity that was expected to be prevented?
Simon Stevens
Yes. Some of it is investment, but some of it also, frankly, is regulatory action. That does not in itself have a price tag, but action to take added sugar out of foods and drinks in the same way as we have successfully done with salt over the course of the last 15 years will show up as reduced rates of type 2 diabetes and reduced rates of diabetic‑related blindness and amputations. If you look at the conversation I was having in this room yesterday afternoon with the Public Accounts Committee on the subject of social care and the emergency hospital admissions and delayed discharges, you can see that the NHS has benefited enormously over the course of the last 15 years from the fact that each generation of older people has been healthier than its predecessor generation. We have been able to accommodate a 52% increase in emergency admissions with the same number of emergency hospital beds because those people are healthier than their predecessor generations. This is a slow‑burn, high‑impact set of changes, some of which are around our public health environment, some of which are regulatory, and some of which rely on the availability of preventive health services, for which there is a price tag. In the context of the spending review, we were pleased that the core public health programmes of which NHS England has stewardship through the section 7A arrangement were protected—that budget was protected—and indeed will allow us to increase some of the preventive activities we want, such as bowel scope screening, over the course of the next two or three years.
Chair
Could I cut in, because the question was quite a specific one? I wonder whether you could answer the question.
Simon Stevens
I think I have, inasmuch as I have said it is a combination of preventive health services plus regulatory action on a range of fronts, including obesity, diabetes prevention, tobacco, alcohol, and the other principal health risks, given that about 40% of the workload of the NHS is related to modifiable health risk factors.
Helen Whately
Was there a figure for the amount that you envisage would need to be invested in public health, and some figures for demand that would be avoided as a result?
Simon Stevens
Yes. Again, if you look at the recap briefing that we provided to the Committee last time, it shows that £4.3 billion‑worth of the demand offset is a combination of demand management activities, service redesign and public health‑related gains.
Helen Whately
Within that figure—because I know the figure you are referring to, as I was looking at it in fact just yesterday afternoon—what is the breakdown between the categories, because, as you say, it was a combination?
Simon Stevens
Yes. It is between £0.5 billion and £1 billion, potentially.
Helen Whately
That is of demand that would be avoided through prevention.
Simon Stevens
Over this timeframe, and obviously there is a sort of back‑ended nature to that, but seen over a five, 10, or 15‑year period the benefits are potentially much greater than that. We calculate—or perhaps Duncan and PHE have calculated—that the NHS has saved £1.5 billion as a result of the 15% reduction in salt in our diet since 2001, for example. Doing the same with sugar will produce the same kinds of benefits stretching out over the next five, 10 or 15 years.
Helen Whately
I appreciate the point that it is back-ended, that there is only so much you can do within a five‑year period, although some, as you have indicated, is expected, but is there an investment in public health measures—prevention—that was required to achieve that?
Simon Stevens
At the very least, we wanted the availability of preventive services to be sustained relative to need. An area where you get very quick payback, or indeed a worsening of the situation if those services are not there, for example, is drug and alcohol services and sexual health services. If those services diminish, that shows up as extra demand in more expensive parts of the national health service within 12 months, not within 10 years.
Helen Whately
Some of the evidence that has been provided to the Committee as part of this inquiry is that many local authorities are cutting back on exactly those services you mentioned—smoking cessation and alcohol services. Are you concerned about the reductions in those services?
Simon Stevens
To the extent that they have an impact on downstream demand, clearly, yes. That said, when we were last discussing this point, I referenced the testimony I think you had had from Lord Peter Smith of Wigan where he, for example, went on record saying that, as a result of the local authority’s ability to commission smoking cessation prevention services, they were, in their opinion, driving much more value out of the money that was being spent and, as a result, were able to square that circle. As to whether the squaring of the circle can continue indefinitely, I defer to Duncan.
Helen Whately
Mr Selbie, you have been keen to contribute.
Duncan Selbie
This needs more work, but if we look at diabetes prevention, which is funded by Simon jointly with Diabetes UK and Public Health England, Public Health England did the evidence review for this. If we look at the longer‑term impact savings to the NHS, it is about £1.2 billion. There might be a bit of spurious accuracy to that and it needs more work, but it flows from the number I am working to, as I chair the NHS prevention board, which is one of the, if you like, Five Year Forward View overall arrangements. We are working to a sum of £0.5 billion over five years, looking at programmes about reducing alcohol harm, reaching long‑term smokers who are in hospitals, avoiding second falls in the elderly, and health at work—a hugely important opportunity. So there is a number, and obviously we would like that number to be bigger, but in a realistic, practical way we think it is about £0.5 billion over the course of the five years. I also want to say that, if we think about this just in terms of money, we miss the opportunity. In the Five Year Forward View we have three gaps, which is the health gap you have been talking about with my colleagues, the efficiency gap and the care gap. We have never had such a conversation, as a system. I have been in the health service for 37 years—it is difficult to tell that, but it has been about that—and we have never had this conversation before. We have planning guidance for the NHS, jointly issued, that emphasised those three gaps, and prevention is at the heart of it; and with STPs, this way of trying to organise on a scale that will make sense—
Chair
Sustainability and—
Duncan Selbie
Apologies—sustainability and transformation plans. They are essentially the planning footprint, if you like. Four out of five of the 44 emphasised that their No. 1 priority was prevention, and we have given them a menu of interventions. Because we have done this jointly, everything goes out in our names together, saying, “If you do these things, you can expect to see this impact.”
Jane Ellison
I want to make a comment about the issue of outcomes versus spend. We have asked a lot of local authorities, since 2010 in particular, in terms of retendering a whole series of services, to reinvent the way they do certain things. Public health stands hugely to benefit from the imagination and rethinking that local government has brought to a lot of the things they do, and you can see from 2013 onwards that local government has brought that fresh pair of eyes to bear on a lot of the services, many of which had previously not been retendered for many years and questions had not been asked, the system had not been stress-tested and things had just rolled along. Over the last few years we have begun to kick the tyres on local services and I have heard the same conversation, the same evidence you have heard, of people saying, “We might be doing less of this or spending less on that.” I am completely focused on outcomes. Duncan is monitoring this like a hawk, but we do not see across the board a drop‑off in good outcomes. We see people looking at old problems in new ways. While I would not ever be complacent and would always be very mindful to check that we are not losing services, that is not the pattern overall that I see. I see a pattern of people coming at old problems in fresh ways and in many cases looking at how they embed solutions right across a local government system rather than seeing it as simply in a health silo. From my point of view, that is exactly why public health has landed in the right place, to end up back with local government leading the way.
Duncan Selbie
May I, with a singular passion, say that it is about the public’s health, if you like, not public health as a profession, a discipline, or a source of expertise, as important as that is. It is about what it takes to improve the public’s health being embedded in local government, to take Simon’s risk factors of, “Do you smoke? Do you drink? What do you eat? Do you ever take any exercise?” and applying that whether that is to diabetes, heart disease or dying in a fire. They are the same risk factors; they matter and we need to pay attention to them. I can talk to local government about what they have been doing about that. You have also listened to my colleagues this morning, but the wider point about the importance of economic prosperity and how that creates new jobs, crucially, that local people can get is at the heart of how we close the gap. As much as we want to put into the public health grant, get the resources out there and focus on prevention and avoiding healthcare, if you like, more positive still is how we avoid it in the first place, which is how we get people into decent work and homes. In my coinage, it is about jobs, homes and friends. Those are critical responsibilities of local government; we want to be seen as a system, not as individual parts.
Helen Whately
I think you have an audience here in this panel who are receptive to that message—absolutely. I also appreciate the Minister’s point that what is most important is outcomes rather than the amount that is spent, albeit that, clearly, the amount that is spent is a means to some of the outcomes. I want to bring us back to that and ask the panel’s view on whether we have the right balance between the amount being spent on public health and prevention versus on care and treatment.
Jane Ellison
I will start, Helen. I would certainly echo Duncan’s point that, depending on how upstream you want to go on public health, there are a lot of things that local government will do that you would never think traditionally of being in a health category—the planning and regeneration of a large estate, for example, as I have seen in my local area, where the public health director is there at the outset as people begin to imagine it. You have that whole kind of macro approach. In terms of the cash, we are giving local authorities more than £16 billion over the spending review period. That is a lot and is just the public health grant, but you cannot see it in isolation. There is also the section 7A funding, which was £1.07 billion in 2016‑17: that is mainly immunisation, vaccination and screening, many of those with very significant preventive benefits of course. Then we in the Department of Health also spend £300 million on the vaccines themselves and there are other investments we do. So there is a lot more than just the public health grant, important though it is, in terms of how we invest in prevention. Overarching that, there is what we do at a national level in terms of system leadership or national legislative change, which Simon has referred to, which amplify the efforts of what is happening on the ground, potentially not just now but for many years to come, such as the sugar‑sweetened beverages levy, the forthcoming childhood obesity strategy, the tobacco plan that ended last December and the new tobacco plan that we are working on. There are things at all levels of Government that can be done that are all about the prevention agenda and, to a greater or lesser extent, they are about going as far upstream as you can to invest in prevention. But some of it is about the here and now, and PHE in particular has identified a number of relatively inexpensive but very effective interventions that will pay back over this spending review period: things like alcohol, nurse interventions at the right moment and falls prevention. These are not 10 or 15‑year payback but payback here and now.
Duncan Selbie
Simon is doing this work on health at work and how we help our own staff to get healthy, using mechanisms like the CQUINs and so on. Does anybody know what that—
Helen Whately
I know we want to cover a lot of ground and I was trying to specifically focus on the funding questions in this bit. I have one final question, which is particularly to have your view, Duncan, on how the funding is going to evolve as we move from the current system to the funding being through the redistribution of business rates, how you think that is going to play through, and the role that Public Health England will play in influencing that.
Duncan Selbie
It is a hugely important question and very much on the minds of local government and directors of public health, because the grant, if you remember, or the ring fence, was never intended to be ad infinitum, and by the time we complete the grant and ring fence it will have been five years, which was at the edges of where I thought we would get to. It was only ever about making sure that it got a good landing and that people had time to think through how this might work. Thinking beyond is something we would have had to have done in any event. We have the first of these big sessions tomorrow. We have about 12 directors of public health, ADPH and the Faculty involved, the Department of Health, of course, is hugely involved, and the Department for Communities and Local Government is involved as well, to begin to think this through. We need to achieve two things. We need to make sure that business rate retention, which we think could be quite a good thing in generating additional resource—it could be spent on improving the public’s health—is fair. It will not work for everywhere, so we will need to ensure there is a fairer way of resourcing, because when the grant was happening it only ever reflected what the NHS had been spending before, which was about a sevenfold variation. In the first couple of years we managed to close that a bit. In fact, some of your local authorities got a maximum of 21%. Nobody got less than 5.5% in the first two years, which was ahead of NHS growth. That closed the gap a bit, but you still have an upwards of sixfold variation against the formula. We do not think that is sustainable. We need to do something about that and make sure that business rates retention works in those places. It is not through lack of effort; it simply is not going to work.
Helen Whately
Is there a risk that the areas of greatest public health need may end up with less money?
Jane Ellison
Can I give the Committee my assurance that we are acutely conscious of that concern? We know that that is out there. It is something Duncan and I have spoken about very regularly since the move to business rate retention was announced, and clearly across Government thought is being given to how we deal with that challenge because—you are quite right—there will be some areas of significant deprivation and, therefore, a particular public health challenge, which may also be challenging in terms of the ability of the local economy to generate business rates. We are very conscious of that, and we will be working through that across Government with colleagues as we move towards that change in the system.
Helen Whately
Briefly to you, Simon Stevens, is there a knock‑on risk to the delivery of the Five Year Forward View from this change in funding for public health, and, given the need to avoid some of that demand that is included in the Five Year Forward View plans, are you factoring in that risk in some of the forward planning?
Simon Stevens
If that risk crystallises, it would be extra pressure over and above what was envisaged when the Five Year Forward View was set out, but, as Jane and Duncan have said, an enormous amount of work was going on to seek to reduce the likelihood of that risk crystallising and instead to capitalise on the potential benefits that come from local authority leadership, which can often go beyond just the commissioning of preventive health services but into a broader array that no NHS body itself would probably be able to tackle. I was struck, for example, by the report in The Observer on 8 May that Liverpool City Council was going to start naming and shaming fizzy drinks brands across Liverpool, given that they have rightly clocked the fact that it is driving tooth loss, weight gain and diabetes for their children. They have some of the highest rates of childhood obesity. So they are going to start naming and shaming heavily sugared drinks and warn parents about the health dangers. A local authority can do that. It would be harder for part of the local NHS to do that.
Mr Bradshaw
It may help the Committee, and also you, in terms of time, to know that we do not need to have the virtues of Marmot or the idea of public health being in local government extolled; the Committee is pretty clear on that. It would be more fruitful for us to examine where some of the challenges are, and some of the perhaps unforeseen consequences of the new landscape have created some problems, which we have heard about in our evidence. First, on the money, Mr Stevens, you were very clear in your Five Year Forward View that it could not be delivered without public health and prevention getting a greater proportion of overall spend, and that has not happened. There have been big cuts, both last year, in-year and in the CSR. So how do you square that circle?
Simon Stevens
To the extent that that pressure expresses itself on the ground, that plus the pressures in social care, about which I was speaking very frankly to the Public Accounts Committee yesterday, are additional pressures over and above the scenarios that were set out in the Five Year Forward View. There is no doubt about that at all.
Mr Bradshaw
So it makes your Five Year Forward View, as you stated at the time, undeliverable.
Simon Stevens
If that is what comes about, it would make it harder to deliver within the low end of the funding scenarios that we set out there.
Mr Bradshaw
Can we move on to the issue of fragmentation, which has been raised fairly consistently among patient groups, user groups and organisations delivering care on the ground—the suggestion that the new landscape, in spite of all its potential benefits in terms of local government and Marmot, has led to more variation and the decommissioning of some services, particularly in the non‑sexy areas of alcohol, drug treatment, smoking cessation and sexual health?
Jane Ellison
Duncan, do you want to come in? We were just talking about this yesterday.
Duncan Selbie
The Committee has heard from my colleagues about the sexual health services, so shall I concentrate on drugs and alcohol? There was a concern at the outset that there would be disinvestment in drug and alcohol services in two respects—one in access to treatment and then the outcomes of treatment. Local government has paid huge attention to this and we have not seen that disinvestment. Population‑level outcomes have remained stable, which the outcomes framework would support, and access has improved.
Mr Bradshaw
Let us move on to sexual health.
Duncan Selbie
If I may say so, I think it is important in that local government has managed to not only sustain but to improve—
Mr Bradshaw
That is great, so what are you going to do about the areas where there are problems?
Duncan Selbie
In drugs, I think it was in 44 areas that we have been working; one of them was yours and in Dr Wollaston’s area we have been working on drugs and alcohol. We worked in 40 or 44 different parts of the country in the last year on drugs or alcohol, where we were concerned with local government that access or outcomes were falling away in some way. In your part of the world, both for drugs and alcohol we saw an improvement, as a consequence, in completion of treatment, which is the principal measure. If I can use that as an example—and my colleagues did it—we do get engaged, in a sense. This is a contact sport. We are not sitting at a distance just watching this or enumerating numbers. Where we see concern, we get involved. Of course there are areas where, for whatever reason, there is concern. The point is: do we know about it? The answer is: yes. Do we get engaged? Yes, we do. Do we make a difference? Yes, we do.
Mr Bradshaw
Are you doing the same on sexual health as on drugs and alcohol?
Duncan Selbie
Yes, we are. We did a full review on sexual health, and we are about to do a further review on sexual health, but we did a full review in 2014‑15, and that led to a whole series of interventions. I could dazzle you with examples from around the country where they are not doing it in the same way. So, if you look at it through an NHS lens, you will not quite see the same thing because they are more focused on outcomes. The Minister made the point; they are just more focused on outcomes and they take advantage of being in a place that thinks in a wider way. I will give you an example. Birmingham had three different approaches, three CCGs or PCTs, looking at the different approaches, and they were essentially paid on activity. The more STIs, the more income they could earn. They have moved to an outcome‑based model, covering the whole of the city, including Solihull, and they are concerned with teenage pregnancy, connections with drugs and alcohol, homelessness and second unwanted pregnancies—the wider set of circumstances, if you like—and they are doing it for less money. That has involved change. That has involved a different way of doing things and a loss for traditional providers. Inevitably, that is difficult, but the eye of the tiger has been on the outcome, which is reducing teenage conception. That is an example. Leeds is another example, as is Norfolk. Under section 75, without going through procurement, they have been able to bring together in a collegiate way health and local government services. Croydon has done the same thing. I could go round the country.
Mr Bradshaw
Don’t worry about that. The outcomes, as we heard earlier, on sexual health are going badly in the wrong direction.
Duncan Selbie
They are not on teenage conception, but they are on STIs, and we are very concerned about that. Professor Newton said there were three areas that we were concerned about: one was STIs. I am happy if you want to take me further on that, but we have been very transparent about where we see the concerns.
Jane Ellison
Before you move on to press that, can I add three quick comments? Of course there are going to be areas of challenge, stress and strain, and we absolutely accept that. One advantage of the way the system is set up now is that we have much greater transparency of outcomes and what is happening in given areas. The National Audit Office review of 2014 was clear that we have completely and vastly improved and increased transparency of public health outcomes, and that does allow us to act. That brings me to my second point, which is the capacity of PHE to be nimble and swift. If someone raises something at a conference in a speech that I listen to or comes to talk to me and says, “This is happening,” or if there are things colleagues have raised with me over the last two and a half years, such as, “I am concerned about x in my area,” I can literally speak to Duncan and say, “Can we find out what is happening on the ground?” If we do not already know—I have to say that 99% of the time PHE already knows and tells me what it is doing about it—it gives us that capacity to act swiftly because we have that transparency, and, as I say, we can then look to deal with it and support local areas. The third thing, just to pick up what Duncan said, is that it has been a difficult time for some traditional providers of services, and sometimes the people who have not been successful in retendering of arrangements, or people who have always done it the same way and then find that the world has moved on a bit and things have been reinvented and done a different way, feel badly about it, and I understand that.
Mr Bradshaw
Of course, and that is part of the process, but, going back to my question, what are you doing about sexual health specifically—the explosion in STIs?
Duncan Selbie
You heard from Professor Cosford. What can I add? The big event for this next coming year is not about further and better understanding of the problem but, “What can we do?” We think it is about reaching 15 to 24‑year‑olds—it might end up being 15 to 19‑year‑olds, but we are exploring this at the moment—using digital platforms across all sorts of activity that the young get involved in, about condom use and raising awareness, and then, of course, getting access to condoms. Much as the work that we do on things like Change4Life, Stoptober, Sugar Smart and so on is important, we are turning our mind to how we can raise awareness and then act on condom use, particularly in the young. There is a whole range of other things about men having sex with men, which, frankly, I would rather you did not ask me hugely about, but it is a big part of getting this right.
Mr Bradshaw
Is that not part of the problem? I am going to come on to this in a minute. This is exactly the problem that a lot of these organisations and charities who work in the field warned about. You fragment the system; there are certain services that local government will never support and never commission because they do not want to talk about it.
Duncan Selbie
No, I did not mean it like that. I meant please do not ask me technical questions about HIV because you had the opportunity to ask Professor Cosford.
Mr Bradshaw
Okay; I am sorry.
Duncan Selbie
We believe completely in integration of sexual health services. We promote that. The guidance that we have issued with NHS England is all about integration at a local level. If you like, it overcomes, “What does the legislation say?” We want to see integration at a local level.
Mr Bradshaw
That leads me on to the role of NHS England, Mr Stevens. In that case you said, whenever it was, that the NHS itself had to be at the forefront of public health. But when you look at a decision like your decision not to commission PrEP, which is widely shown to be effective and cost‑effective in reducing infection rates and therefore in reducing costs to the NHS hugely in the long term, how does that square with the commitment you made and what Mr Selbie has just said?
Simon Stevens
PrEP has great potential, and all of us would like to see it made more widely available in this country. A specific legal question has arisen about the legal powers of NHS England; and the external legal advice that we have had, and transparently and openly published and shared, suggests that it would be ultra vires for us to do that. Were we to commission in a way that was ultra vires, we would be subject to censure by the National Audit Office and others. There are differences of opinion about that, naturally, and we expect to have those resolved through the agreed legal process with the relevant advocacy organisations within the next six to eight weeks. But even when it is resolved one way or another, whether we do have those powers to commission or whether the responsibility sits with local authorities, given their sexual health prevention functions, or the Department of Health through section 7A arrangements, whichever the right answer is—there will be an answer, a clear answer—then the question will be what the investment and the roll‑out of those kinds of programmes should be. The fact is that there are a number of stages that would have to be got right before that could be automatically assumed. In particular, even if NHS England was the responsible commissioner, it would mean that PrEP would go into a prioritisation programme this year alongside lots of other candidate treatments, and, as is no secret to this Committee, the finances of the national health service are rather constrained at the moment, so it is going to be a very difficult process of selecting the most impactful of the candidate treatments. In that scenario, PrEP would be up against cystic fibrosis treatments, organ rejection following heart transplantation treatments, Parkinson’s disease, other HIV therapies, kidney disease and multiple sclerosis. We have published the whole list. We have made all this perfectly transparent. I do not think one should assume that, even if NHS England specialised commissioning was the responsible commissioner, it would automatically mean there would be £10 million-plus to spend on this this year.
Mr Bradshaw
Are you as confused as to who is responsible for commissioning treatments for those diseases as you are for HIV?
Simon Stevens
There is no legal doubt there. It is pretty clear that those have been specifically assigned to NHS England through the prescribed specialised services regulations.
Mr Bradshaw
So what is the problem? It is not acceptable, surely, that no one knows who is responsible for commissioning a treatment.
Simon Stevens
Yes, and the 2013 regulation specified that responsibility for sexual health preventive services sits with local authorities. That has been challenged, and that challenge will be resolved, we hope, with our support, within the next six to eight weeks.
Mr Bradshaw
You would support it coming to you.
Simon Stevens
I would support resolving that uncertainty one way or another. It will then be clear. Let us also recognise that at the moment, as proposed, this particular drug is not yet licensed for prophylactic treatment for HIV, and, frankly, the prices that the manufacturer is seeking to charge probably also need to take a substantial haircut to represent good value for patients and for taxpayers in this country. A number of things have to be got right in partnership with patients’ organisations and others in order to make this intervention available.
Mr Bradshaw
What is the public health Minister’s view as to where this responsibility should sit?
Jane Ellison
We know PrEP can make a difference to some of those at risk of contracting HIV and so we do need to get a full understanding of all the issues surrounding it. I do not think we have that full understanding yet. Simon is right to say we will resolve this issue, but there are a lot of things we need to work through first. That is why the Government have called for an evidence review. We have asked NICE to conduct that evidence review of TRUVADA and its use in HIV in high‑risk groups, and that will help us inform decisions about future commissioning. The other thing is that we need to see it in the context of a health service cost‑effectiveness view. There has been the PROUD study, but we have not looked at it in the broader context of how it sits alongside other cost‑effective interventions. To go to your earlier point about STIs, it still leaves us with a very significant challenge around rising STI rates, for example. Clearly, we recognise that PrEP has a role. Other countries around the world are also going through this process of understanding what that role is and how it is to be commissioned. I had a conversation very recently with the chief medical officer of Australia. They have just launched a major trial. The NHS has said it is putting £2 million into a trial. So, alongside calling for the evidence review from NICE, we are planning to move ahead with a trial, and we want to give an assurance to those people who were on the PROUD study that we are looking to make sure that they are picked up as we go forward as part of that trial. There is a lot of work going on, out of which will come a better understanding of the role that PrEP can play, but, while it is important, it is not a silver bullet, and I think it is important to say that. We have very significant challenges, as you have said, around rising STI rates in the MSM community; we have growing challenges around, for example, drug‑resistant gonorrhoea and some other really difficult and challenging diseases; and we need to think about how we address those in the round. PrEP alone is not a silver bullet in response to all those things.
Mr Bradshaw
It might be helpful to have slightly shorter answers, but, finally, on this section, Chair, there is the problem of stigma, which I am sure you would all recognise is really dangerous when it comes to public health policy. There is a feeling out there, whether you are talking about the decision on PrEP or your capping, Mr Stevens, of the availability of a new drug treatment for people with hepatitis C, that we are going back to the bad old days of certain sections of the community being stigmatised, and that will make the problem a heck of a lot worse. How do you respond to that?
Jane Ellison
Can I come in first on that? I absolutely reject that. I would say that in the last two and a half-plus years that I have been public health Minister, one thing I have been most acutely conscious of is the need to give system leadership in talking to communities and groups that sometimes do not get that attention. For example, I held a summit just before the last general election on TB, specifically looking at the needs of communities affected by TB in the homeless community. I have gone out of my way to support things like Find & Treat services. I am told I am the first Government Minister to go on a platform and talk regularly about chemsex and the challenges that that has brought to the MSM community. Only last week, we announced the roll‑out of a very major trial in the use of the HPV vaccine for MSM. I understand why people might have those concerns, but I absolutely reject them. I am very conscious, as public health Minister, of the need to do the opposite—to seek out those groups of people whose healthcare needs are perhaps not spoken about as often, to make sure that those get due publicity.
Mr Bradshaw
Mr Stevens, what about your decisions on hep C treatment in this context?
Simon Stevens
We are following NICE’s recommendations in this area, and let us just be clear about this—
Mr Bradshaw
They did not recommend a cap, though, did they?
Simon Stevens
They recommended the phased roll‑out. Hepatitis C treatments will be the single biggest new investment the national health service made last year and this. We are putting in £200 million of extra funding in order to roll out this treatment, starting with those patients who are most severely ill. We treated the first 5,000 and are working through the backlog of patients with chronic health problems on a phased basis. Frankly, in the real world, if we had said, “We are going to spend £1 billion or £2 billion this year on hepatitis C,” the NHS would have been cutting lots of other services to do so. So it is perfectly reasonable, as NICE recommended, that we, having made this big investment of £200 million a year, do so on a phased basis.
Julie Cooper
During the course of our evidence‑gathering sessions we have had some mixed or split opinions about the movement of public health functions to local authorities, but one area where there has been universal agreement has been around embedding health in all policies in local government. We have also seen a great variety in roll‑out on this. We have seen some really good provision in Coventry, for example, where they are doing excellent work. What is your view, perhaps starting with you, Duncan, on whether we should be doing more via legislation to make sure that some best practice is embedded? For example, should we be introducing material health considerations in all licensing and planning decisions by way of legislation?
Duncan Selbie
That is interesting. Coventry is not unique, but it is pretty good, is it not? My mind has immediately gone to the work that is going on around devolution in a number of different parts of the country. In Greater Manchester—everybody talks about them—there are five or six public health outcomes that are truly cross‑everything, if you like: things like reducing the number of low‑birthweight babies and raising the number of parents who are in work, that sort of thing, much more than about traditional—
Julie Cooper
There has been lots of good practice, and we have heard about that. Specifically, do you think we should be legislating to make sure that this good practice is shared where authorities are not being quite as proactive sometimes as others?
Duncan Selbie
No, I think it is happening. The conversations are going on all over the country. In the north‑east, I chair the commission on health and care integration; in London and the west midlands, it went live last week. All over the country these conversations are happening. In fact, the planning that we are doing together is about emphasising something from Scotland. If I may say so, once the pound reaches Scotland it loses its identity, in a sense and is not an NHS pound, a local government pound or a police pound but a place pound, so we are emphasising taking the totality. Sheffield is an example. If you take the public health grant, it is £32 million; if you take the local government spend it is £1.4 billion. If you take Sheffield’s spend, it is £4.5 billion. They need to be concerned with the £4.5 billion. On specific things that local government is asking for, the most consistent is around a health objective in licensing. Our evidence review on sugar talked about the importance of helping local authorities have more influence over proximity and intensity of fast food and things like that. I cannot pre-empt what the Government are about to say on that, but, of course, in public health terms we are very keen to support local government in helping people to make these changes. Does that help?
Julie Cooper
Thank you. That is helpful. Minister, do you want to comment on that?
Jane Ellison
There are considerable powers that local authorities already have, and, interestingly, in conversations we have had with local authorities and through the LGA it is clear that different authorities use the powers they have differently and some have demonstrated the ability to use their planning powers. For example, they have become very proactive already. That being said, as you would expect, we are looking right across the piece at what every part of society—national Government, local government, industry, families, schools and local communities—can do to address the issue of childhood obesity, and we will be saying more when we publish our strategy this summer.
Julie Cooper
We might be hearing about legislation yet in the pipeline.
Jane Ellison
There is more for all to do. It is a huge societal challenge and we believe that all sections of society can be part of the solution.
Julie Cooper
Moving on from that, we have talked about local government embedding health in all its policies, but are national Government doing enough and what progress is being made interdepartmentally in every policy the Government make? Is health a material consideration?
Jane Ellison
Yes, I think very much so. Let me give you some specific examples. We work very closely with other Government Departments on a whole range of policies. One example is health in work, which Duncan alluded to earlier. There is a joint unit between the Department of Health and DWP recognising that mutual relationship between health and wealth. There is the Government’s life chances strategy; I sit on the cross‑Government steering group for that. We have been working for many months on a significant health component of that, looking, for example, at the sort of issues that help a child to be school ready. Now it is really accepted that what you do in early childhood has an effect throughout one’s life. I do not think in 2010 that was necessarily embedded at the heart of our thinking and it is now. Health runs through the life chances strategy like a name through a stick of rock. As to childhood obesity, the childhood obesity strategy is a Government strategy. It was a manifesto promise last year. It is a Government strategy, and we are working with, at my last calculation, at least five or six other Government Departments, if not more, to look, as I said, at all the factors that contribute to children becoming overweight or obese. So, yes, I think that more and more we are working right across Government, and not just talking the talk, in a way that embeds it and acts on it.
Julie Cooper
How often does this cross‑Government group on public health meet to consider the issues cross‑Government, and how are the conversations or how is the work documented? Is it formally documented?
Jane Ellison
Let me say a word about how I work, but then I want to ask Duncan to comment because he is doing great work across Whitehall. In terms of how we work and the issues I have just mentioned, those are specific pieces of work with specific outcomes to come out of them. The work is documented in the normal way the work of Government is documented, and you will judge us by the output. Before my time as public health Minister, there was a Cabinet sub‑committee. I have never sat on that; I think it stopped meeting before I was appointed. But my own view is, sitting on quite a number of sub‑committees as I do, that I prefer to work, in many ways, with a very defined outcome, a policy objective, a strategy or a new policy to deliver, and then we can be judged by our output and the outcomes. I do not think that talking for its own sake is always the best thing. It is better to meet with a purpose, and those are three areas in which I can say that we are meeting across Government with clear purpose. Duncan perhaps can say more about the work he is doing at official level.
Duncan Selbie
Briefly, as to health in all policies, of course health is about more than healthcare, so all these Departments have a fundamental contribution to make. I have met 10 permanent secretaries in the last six months. When you go into Transport, they want to talk about active travel and air quality. When you go into DCMS, they want to talk about the sports strategy. If you go into education, they want to talk about the No. 1 thing that would help if a head teacher had 20 minutes more in a day. How would they use it? The answer is to get the children moving more. It goes back to these risks that we talked about before. One new thing that might be of interest to the Committee is that, if you went back two reorganisations ago, when you had regional directors of public health embedded within the Department of Health, they used to have, if you like, another Department that they partnered with. What I have been offering as I have been going around Whitehall with the permanent secretaries is whether we can reinvent that so that education has a senior public health professional, likewise DWP, BIS— there is quite a range of them—and the Ministry of Justice on what happens in prisons. That is what we are doing at the moment. I am writing, as we speak, to all of the 10 I have met to make them that offer. This is not to say, “This is what we want you to do.” It is to listen hard to what they are trying to do and ask if there is some way in which we can help, and also join things up.
Jane Ellison
The MOJ is another good example.
Duncan Selbie
The MOJ is a cracker.
Jane Ellison
Only last week we had meetings with colleagues in the MOJ looking at the support for prisoners’ health, and in particular people’s pathways out of prison back into the community and how we are trying to smooth that pathway in terms of their healthcare needs, if, for example, they have substance abuse issues.
Julie Cooper
This all sounds like pockets of really good work, but it seems that local government is still leading the way on this. In the best authorities, health and wellbeing underpin every policy, and surely that would be the ultimate outcome. It would be really useful, it strikes me, for example, for the Minister for the Department of Work and Pensions to have at the heart of every policy that they bring forward within that Department a consideration of the health effects and wellbeing of the policy. Do you agree that to formalise this very good practice that is already going on in pockets would be the next step forward?
Jane Ellison
I would say it is formal already. You cannot get more formal than a joint unit between the Department of Health and DWP, for example, to look at health and work.
Duncan Selbie
I am going on tomorrow to be part of the joint committee about getting people back into work and how to get people who have a job but are unwell back to work even faster. We are doing similarly across Government on air quality. It is a journey we are on. I think local government has been at it for longer and has done it really well. It is inspirational, I know, but inspirational in parts of the country, and we want to level up. I am seeing, even in a short period of time, that the ambition and appetite for doing this across Government is genuine. We will see that in child obesity, but there are other areas. The most obvious of those is about getting people back into work.
Dr Whitford
Still on that, Marmot and all the evidence always shows that the biggest killer and health impact is deprivation, as you have mentioned yourself, Duncan. Talking about supporting people who are working and getting them back into work, what about the changes that we have had for people who are not working or are not able to work? The UK Faculty of Public Health’s report that they did with one of the cross‑party groups here, “Health in All Policies”, was suggesting that we were seeing poverty rising and that we were going to see it rising further. That might be fine for the people who are in work or can work, but the problem is that, if we leave a whole chunk of the population behind, due to disability, mental health or whatever else, how will we tackle the problems that causes?
Jane Ellison
At the heart of the Government’s life chances strategy is a simple proposition that we want to tackle every single underpinning factor that prevents a child getting on and making the most of their life. That means a real deep dive on the drivers of poverty—issues like debt, addiction and family break‑up, all those things. It might be a point of political difference, but my own view is that attacking those key underpinning drivers of poverty is absolutely critical to how you tackle this in a way that is transformational. We have tested to destruction the idea that money alone is the answer to the problem in previous Administrations, and I do not believe it is. I think that at the heart of the life chances strategy is the very proposition that you say—which is looking at the poorest people and the least advantaged in our society, particularly children, and understanding what are the things that can affect their life chances as they grow up and that will give them the best chance to be successful in life.
Dr Whitford
I do not think any of us in this room thinks that money is the whole problem, but it is certainly a chunk of the problem. If you do not have money, if you are struggling to keep a roof over your head or food on the table, it overshadows thinking about whatever else you are doing, and certainly their view in the evidence that we heard in that inquiry was that they see child poverty rising because children live in disabled families, in unemployed families, and many of those families are seeing their income going down. Is that not a combination of the Treasury and DWP not hearing “Health in All Policies”, because those people will cost more in the longer term?
Jane Ellison
We are straying beyond my portfolio. I would simply say that work is vital to health—
Dr Whitford
Is that not the point?
Jane Ellison
—and we have record numbers of people in employment, and the number of children in unemployed households has dropped over recent years. All those things help us to drive change in this area.
Dr Whitford
But surely we have increasing in‑work poverty. Two thirds of children who are defined as living in poverty have a working parent.
Jane Ellison
I think we might have to agree to disagree on that.
Dr Whitford
But surely whether you and I agree is not going to change the fact that those children are living in an impoverished family.
Jane Ellison
I have given you my answer.
Emma Reynolds
To what extent does Government policy join up on this, though, having regard to the policies of the Treasury and particularly the Department for Communities and Local Government? Mr Selbie, you made the point about how the worst health inequalities are found in the most deprived areas. What kind of join‑up is there between the different Departments? There is only so much you can do as a public health Minister if the other Departments are working against you.
Jane Ellison
I made the point earlier that, if you take something like the life chances work that is going on, there are 10 or 12 Government Departments all represented in looking at that. It is a completely cross‑cutting strategy, with a view to looking not just at the different factors that drive poverty and lack of opportunity but how those policies interact and how the Departments interact. That is the point of getting everyone round the table. I agree with you about working in silos; you can never hope to tackle the most intractable problems, but we are not working in silos any more.
Duncan Selbie
That is what will close the health gap over five, 10, 15 or 20 years. We know how much this matters.
Dr Whitford
Do you feel you are focusing and breaking down these barriers?
Duncan Selbie
Yes; I see it at a local level and at a national level. I am not sure anybody would have thought three years ago that it was possible that we would have a child obesity strategy or plain packaging for cigarettes. The focus that we have now is on health at work, with the DWP and the DH, supported by Simon and me, and on how you get the million or so people who really struggle to get to back into work. That is the forecast, because we know that is what will make the biggest difference. Children in very low-income, poverty-in-work income homes, do better than those in homes that have no work at all. We need to see work as a public health objective. It is a public health objective.
Dr Whitford
I totally agree with that. Can we move on, because we are running out of time. Some of the comments we heard from people who gave evidence to us were that, now that public health had moved into local authorities, it was as if the NHS was washing its hands of it. This is particularly to Simon really. Do you recognise that? What proportion of trusts do you think have a really proactive preventive agenda?
Simon Stevens
Of trusts, of hospitals or the CCGs?
Dr Whitford
Pure NHS, if you like.
Simon Stevens
I do not recognise that because I do not think this is a zero‑sum situation. I do not think, because you have enhanced local authority leadership, that means you have diminished NHS involvement necessarily. The Association of Directors of Public Health have pointed out that there are in some places issues around the extent to which directors of public health are able to influence what the CCGs or the NHS are doing, but I do not think that is intrinsic to the model as evidenced by what we have seen in some of the other great local authorities where this has worked well.
Dr Whitford
Do you think there should be a strategy laid down where they have a commitment to go on, as in “Making Every Contact Count” and so on, rather than feeling this is now no longer their business?
Simon Stevens
Yes; I absolutely agree that it continues to be their business, and if you think about what we are doing, as Duncan said earlier, through the local implementation process for the Five Year Forward View, we are focusing, in all 44 of the communities that have come together in England to do this, on the health and wellbeing gap as well as the care and quality gap, and the financial sustainability and efficiency challenge. So I think this is better understood now in the NHS than it was perhaps five years ago, and in quite interesting ways. I think about the conversation I had with the deputy director of public health for the Royal Free Hospital. Since when did teaching hospitals have directors of public health? It turns out that some of them are clocking the fact that this is an important part of the impact that they have in their local communities, and indeed with their own staff. So, as Duncan said, the NHS as an employer, as the biggest employer in Europe, has a responsibility to put our own house in order when it comes to workplace health, which traditionally we have not done. This year, which we are now in, we have the world’s biggest incentive programme for employee health in our health system, with up to £450 million of incentives tied to improving workplace health for nurses, therapists, ancillary workers and others across the NHS.
Duncan Selbie
They get picked up through the NHS prevention board, so this is us working together. PHE supports a provider network; there are about 30 or 40 hospitals that have invested in public health specialists. Barts has a director of public health—and Oxford, Addenbrooke’s and West Birmingham—because they know that their part in prevention is going to help them in managing demand as well.
Dr Whitford
Do you think that sustainability and transformation plans are going to help to change the kind of negative feedback loop of how trusts have been paid up till now? Certainly what we heard was that the NHS providers are paid by work they do, not work they prevent, and one problem is that local authorities invest the money, but the saving goes to the NHS. Are you hoping to tackle and change that structure so that they both share in the benefit of the work they do?
Simon Stevens
We are. Obviously it is a slightly more nuanced picture than that, given that there are different funding incentives in different parts of the health service, let alone between the NHS and local authorities. But if you take Ben’s area—Devon, for example—they are coming together now as a collective care system in a way that even 12 months ago would probably have seemed implausible. We have styled it “The Devon success regime”. Maybe after a little bit of a slow start, I do think now they are motoring. I stand to be corrected by Mr Bradshaw, of course, but that is an example of beginning to think more holistically across individual organisations, and, indeed, the chief executive of Mr Bradshaw’s own hospital has become the leader of that collective endeavour for Devon.
Mr Bradshaw
She is doing an excellent job.
Dr Whitford
So we are moving back more to, in essence, place‑based management of the issues.
Simon Stevens
Yes.
Chair
Thank you. Time is rather short, and I know that, Simon, you have to leave at a quarter to 12. One of the purposes of this inquiry was to look at the changes that have happened since the Health and Social Care Act. Are there aspects of the legislation that you think need to be revised in the light of your experience since becoming the chief executive?
Simon Stevens
That is a nice little poisoned chalice to sip from at the end of this inquiry. There is a bit of a sense that, wherever we have got to, there is not a huge appetite for throwing all the cards up in the air and starting again. So, to the extent that there are elements of the system that are evolving, there are some de facto workarounds that are being put in place, going with the grain of what people can see is needed and focusing on the practical stuff rather than the administrative reorganisation again. My mantra on this is that there is no right answer as to what these arrangements look like, but the wrong answer is to keep changing your mind.
Chair
But are there aspects of the legislation that you feel need to be revised because the workarounds simply cannot take place or they are too cumbersome? Are there recommendations that you would like to make to this Committee?
Simon Stevens
Do you mean particularly on public health?
Chair
Particularly on public health, but if you want to expand it further, that would be fine too. The focus of this inquiry is on public health. I know you are coming back at a later date and we will perhaps have more time to expand on the other aspects of the legislation, but, particularly as regards public health, are there aspects of this where you are finding that a workaround is proving very cumbersome or that the Government should be tweaking the legislation?
Simon Stevens
This new system is bedding in. There is opportunity, created particularly by the local authority leadership role, but that comes at the expense of some complexity, given the way some of the different funding streams connect; and so there is a trade‑off there. Rather than relitigating that trade‑off, I think we should go full strength to make these current arrangements work as best we can and then, in the fullness of time, properly answer your question.
Chair
Thank you. I know that you have to leave us at this point, so perhaps I could expand that to you, Minister, and Duncan Selbie.
Jane Ellison
I am getting slightly short of time, because, as you know, I have an urgent question to add to my two debates from last night. Parliament’s appetite for public health knows no bounds. No, I do not think so, and I would concur with the view just given. I do not think there does need to be legislative change. We face some challenges as it is a new system bedding down, but we have seen, from my own perspective, enormous potential in just a few years of the way the public health arrangements sit now. At the heart of all the frustrations it is about bedding in good relationships, and I think, in the end, you do not legislate for good local relationships and great leadership. Key relationships and great leadership are the key to making it all work, and that would be true in any system construction. That is why we are investing heavily in the public health workforce, in senior management and senior leadership, and why we have to keep working at those local relationships. When we see people crack it at a local level, we see its enormous potential.
Chair
The difficulty comes where those relationships are not good. What levers and mechanisms are there to step in for the benefit of local communities?
Jane Ellison
I understand that challenge, Chair, but I do not think you would ever legislate for that. That is about making sure that we have the right system leadership, from the Department, from the head of Public Health England, and from the top of the NHS, to make those things work.
Chair
But do you have the levers if that is not happening at local level? I accept you cannot legislate for that, but do you have the levers you need?
Jane Ellison
We have a number of levers, but I am a sceptic as to the extent to which you would pull a lever in Whitehall in any system and something would change hundreds of miles away. In the end, you will always need to put your key system leaders on the ground to identify where the local leadership stands and how you bring people together in a health system that perhaps was struggling to work.
Chair
Can I just raise one example where some concerns have been expressed by the Institute for Government and others, for example, about the status of Public Health England as an Executive agency? We have had a number of witnesses tell us that it should be at greater arm’s length, and I wonder whether both you and Duncan could comment on that.
Jane Ellison
I have heard that too, but I just do not see that. I know there was a very active debate during the passing of the 2012 Act around the status of Public Health England and how it would operate, but I think it is operating well. The Department does need an Executive agency to be able to take forward the kinds of things that parliamentarians raise, all those things, but at the same time I look at the time Duncan has spent, for example, just in the field over the last couple of years. He has met every head of every authority over the last two years. Is it two years, Duncan?
Duncan Selbie
It is two and a half years.
Jane Ellison
I think that, while the system is still settling down, Public Health England is settling down in that system very well and performing well.
Chair
It is performing well, but does Public Health England have sufficient independence to be able to challenge—
Jane Ellison
Chair, we gave that a good run‑out last summer, did we not, when in fact your Committee asked for the evidence and we had a little bit of a delay, but then you got the evidence on the impact that could be made on sugar consumption? That evidence was presented. It has sat there. It has been an incredibly useful reference point.
Chair
It was helpful indeed, I think, having it in the public domain at the end of the day.
Jane Ellison
I absolutely concede that, and it was helpful, has been helpful and continues to be helpful as a reference point to Government as we look to formulate policy.
Chair
Perhaps turning to you, Duncan, do you feel you should now have a different status?
Duncan Selbie
Can I be very blunt? I am not interested in whether it is an Executive agency, non‑departmental or executive—all these different things. What we are independent to is the evidence, and that includes professional judgment, because there is not evidence about everything. We are not constrained. I said that to you when we had the conversation. There was a wider set of issues that I was seeking to convey. The ultimate arbiter of my independence was the right to choose, and I was choosing not to in that particular circumstance. It was uncomfortable but necessary. The critical thing for public health and for the public’s health is the independence, the freedom to speak and to publish evidence. That is irrelevant to organisational form. For the record, can I pay a huge tribute to local government for what they have done in the last three years? I do not think we say sufficiently just what a fantastic embracing they have done of this new duty. It is apolitical. It does not matter where you go. As the Minister says, I have been to pretty much everywhere, and there is an inseparable partnership—it is really good that you had Simon with us today—with the NHS.
Jane Ellison
I echo Duncan’s words. I do not get out as much as I would like to, but everywhere I go in the country, irrespective of political leadership, I am so impressed by what local government is doing with these new powers and I have great faith in the fact that they can be better still.
Chair
Thank you very much. I know Ben has a final point and then we will finish.
Mr Bradshaw
It is one I wanted to make to Mr Stevens, but instead I will have to make it to you, Mr Selbie. The Minister has made quite clear that she thinks Brexit would be very damaging to the NHS and to public health. Mr Stevens has made it quite clear that he thinks Brexit would be very damaging to the NHS. We heard quite a lot of evidence from leading experts in public health that they thought it would be disastrous for public health, given the role of environmental impacts and so forth on public health. What is your view on the potential impact of Brexit?
Duncan Selbie
I am not getting into it. Our first duty is to protect the health of the people, which we will do irrespective of whatever. It is the drop dead, No. 1 priority. You have heard a lot about that this morning, so, whatever happens in the world, that is what we are for, No. 1. Secondly, we will improve the health of the people, and that is a system‑wide thing, which is exactly what the Minister and Simon are talking to. It is not owned by us, but, by heavens, we have a contribution to make and we are very proud of it.
Mr Bradshaw
So do you not have a view on the impact of Brexit?
Duncan Selbie
I have answered. It is of no consequence to me as the leader of the public health system in England—we will work with the world in protecting the people of this country irrespective of the governance arrangements. I really do not want to go further.
Chair
That is fine. You have made that clear. Thank you very much, and thank you both for coming today. Oral evidence: Public Health post-2013, HC 140 30 [1] The software package referred to throughout Q328 is called ImmForm, not PREP. [2] Amendment by Professor Cosford: “I said I did not yet know whether it was cost-effective.”