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Public Health

Volume 722: debated on Tuesday 30 November 2010


My Lords, with the leave of the House, I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health.

“With permission Mr Speaker, I would like to make a Statement on public health. Today, the Government publish a public health White Paper with two clear aims: first, to protect and improve the health of the nation; and, secondly, to reduce health inequalities by improving the health of the poorest, fastest.

The need for this White Paper is beyond question. Britain currently has among the highest rates of obesity and sexually transmitted infections in Europe. Smoking still claims 80,000 lives a year. Alcohol-related admissions to hospital are unacceptably high and, in recent years, inequalities in health have widened, rather than narrowed. As Professor Sir Michael Marmot’s review to my department put it,

‘dramatic health inequalities are still a dominant feature of health … across all regions’.

There is a seven-year gap in life expectancy between the richest and poorest neighbourhoods, but a gap of nearly 17 years for disability-free life expectancy. About a third of all cases of circulatory disease, half of all cases of vascular dementia and many cancers could be avoided by reducing smoking, improving diet and increasing physical activity.

We need to do better, and we will not make progress if public health continues to be seen just in terms of NHS provision and of state interventions. Two-thirds of our potential impact on life expectancy depends on issues outside healthcare. Factors like employment, education, environment and equality all are determinants of health. They are, as Michael Marmot put it,

‘the causes of the causes’,

the underlying factors leading to poorer health. Unhealthy behaviours, like drinking too much, smoking or taking drugs are part of a complex chain of individual circumstances and social causes, typically rooted in poor aspiration, adverse peer pressure and low self-esteem.

The human cost of poor health is obvious. So, too, is the financial one. Alcohol abuse costs us an estimated £2.7 billion and obesity costs an extra £4.2 billion each year to the NHS alone. And, while there are things we can do to help, we cannot resolve all the difficult issues from Whitehall. Hence, this White Paper has one clear message above all others: that it is time for politicians to stop telling people to make healthy choices, and time to start actually helping them to do it.

There will be a profound shift in tone, attitude and outlook. Rather than nannying people, we will nudge them by working with industry to make healthy lifestyles easier. Rather than lecturing people about their habits, we will give them the support they need to make their own choices and, rather than dictating policies from the centre, we will support leadership from communities by giving local authorities more power to develop the right approaches for their communities.

This White Paper is a genuine cross-government strategy. Through the Cabinet Sub-Committee on Public Health, we will put good health and well-being at the heart of all our policies. To do so, we will recognise that we need to provide support at key times in people’s lives. We will not only measure general well-being, we will seek to achieve it.

For instance, because we know a mother’s health is key to a child’s health and development, we are investing in Sure Start children’s centres and 4,200 more health visitors to give families the support they need. Because we know that those who are unemployed for long periods are more likely to be admitted to hospital and more likely to die prematurely, we are transforming the welfare system, ending the benefits trap, and making sure that work always pays through a single universal credit. Because we know more people would cycle to work or school more often if there were safer routes for them to use, the Government are investing £560 million in sustainable transport.

Subject to parliamentary approval, there will be a new dedicated public health service—Public Health England—which will provide the resources, the ideas, the evidence and the funding to support local strategies. Public Health England will bring together, within the Department of Health, expertise from a range of public health bodies, including the Health Protection Agency, the National Treatment Agency for Substance Misuse and the Chief Medical Officer’s department. It will work with industry and other government departments to shape the wider environment as it affects our health. It will also develop health protection plans”.

I am awfully sorry to disturb the noble Earl and I am sorry to have to ask two very venerable noble Lords if they would mind having their conversation outside the Chamber as suggested in the Companion to the Standing Orders. I cannot concentrate on what the Minister is saying.

The Statement continues:

“It will also develop health protection plans and screening programmes to protect people from health risks. Because we also know that the foundations of good health are rooted in the community, often at a neighbourhood level, we must strengthen and renew local leadership to ensure that these efforts reach deeply into communities and match their unique circumstances.

Under this White Paper, the lead responsibility for improving health will pass to local government for the first time in 40 years. We intend to give local authorities new powers to plan, co-ordinate and deliver local strategies with the NHS and other partners and to embed the foundations of good health in ways that fit local circumstances. Directors of public health will provide strong and consistent leadership within local councils.

We also intend to establish the new local statutory health and well-being boards as a way of bringing together the NHS and local government. Whereas before, public health budgets were constantly raided by other parts of the NHS, we will prioritise public health spending through a new ring-fenced budget. We will look to the highest standards of evidence and evaluation to ensure that this money is spent wisely. The new outcomes framework for public health, on which we will consult shortly, will provide consistent measures to judge progress on key elements across all parts of the system—nationally and locally. The framework will emphasise the need to reduce health inequalities and will be supported by a new health premium incentivising councils which demonstrate progress in improving outcomes.

We have learnt over the last decade that state interventions alone cannot achieve success. We need a new sense of collective endeavour—a partnership between communities, businesses and individuals, which transforms not only the way we deliver public health, but also the way we think about it.

Through the public health responsibility deal, the Government will work with industry to help people make informed decisions about their diet and lifestyle, to improve the environment for health, and to make healthy choices easier. Through greater use of voluntary and community organisations, we will reach out to families and individuals and develop new ways to target the foundations of good health. Reflecting the framework in the ladder of interventions developed by the Nuffield Council on Bioethics, we will adopt voluntary and less intrusive approaches so that we can make more progress, more quickly and resort to regulation only where we cannot make progress in partnership.

This is a time when the NHS and social care are under intense pressure from an ageing population and higher costs. It is a time when we must therefore put as much emphasis on preventing illness as we do on treating it. In the past, public health has been a fragmented and forgotten branch of the health service. This White Paper will make it a central part of everything we do, and we will bring forward legislation in the new year to enact these changes.

By empowering local authorities, by strengthening our knowledge of what works and by establishing the right incentives to drive better outcomes, the White Paper will deliver the strategy and support needed to reduce health inequalities and to improve the nation’s health. I commend this Statement to the House”.

My Lords, that concludes the Statement.

My Lords, I thank the Minister for repeating the Statement, which as we know was well trailed on the “Andrew Marr Show” on Sunday and on the “Today” programme this morning. There are some things that we would like to welcome and support in the Statement, and there are some that we think are a cause for concern. My overall impression is slight disappointment at the insubstantial nature of this Statement. Much of it is common sense and much of it picks up where the previous Government left off, but the Government have had quite some time to think about and to decide on the direction for public health. I believe that this White Paper is short on strategy. Therefore, I look forward to more substance as we move forward.

I think that we would agree that local authorities have an important role to play in the delivery of the public health agenda. Presumably, the new public health service will take on some of the responsibilities of the Health Protection Agency. I have to say to the noble Earl that I wonder why it was necessary to announce the abolition of the HPA, except to make a political point, which is disappointing, when a new agency is being created. The appointment of the new directors of public health will be very important in this programme of delivering a public health agenda. For them to be effective, they will need to be independent. How do the Government intend to ensure that directors of public health in local authorities have the necessary independence and power to deliver an agenda, which sometimes a local authority may not want to hear and may find expensive to deliver?

I am disappointed at the cheap gibes in the Statement, which I can only assume were the idea of the Minister’s bosses—that the nanny state ruled during the Labour years and that Mr Lansley’s “nudge-nudge” public health strategy will be more effective. We need to get past that sort of name calling. The evidence shows that by taking a lead, as Labour did, in the diagnosis of public health issues based on evidence and in taking some of the big decisions on, for example, smoking, exercise and diet—the noble Earl has not ruled out that this Government might need to do that too—we provided a good framework for people to take responsibility for their health and to start to change their habits. I hope that this Government will continue to support families where it is needed.

I do not think that nudging would have got us the ban on smoking in the workplace. “Nudge” will not replace the brilliantly successful schools sports programme. I am not sure that nudge will deliver the national screening programme mentioned in the Statement. I am certainly sure that nudge will not deliver healthy meals in schools or fruit for schoolchildren. So I am sceptical about the nudge part of this Statement.

However, we can all agree that factors such as unemployment, education, environment and equality are important determinants of health. The Statement is correct in saying:

“Unhealthy behaviours, like drinking too much, smoking … are … rooted in poor aspiration, adverse peer pressure and low self-esteem”.

As Marmot puts it, and as the noble Earl has said, they are the “causes of the causes”. That is absolutely correct.

I disagree with this Statement where it puts forward a cross-government initiative; that is, joined-up government. The noble Earl needs to explain how throwing somewhere between 400,000 and 500,000 people on the dole will help their self-esteem and their family’s prospects. He would need to explain the joined-up bit of the Government that led his right honourable friend the Secretary of State for Education to get rid of the successful school sports scheme that got our nation’s children playing sport. Ditto housing benefit cuts, which may put some families’ homes at risk or move them away from where they can earn a living. That is not going to provide the right environment. Finally, we have the abolition of the education maintenance allowance, which has allowed thousands of children from low-income families to stay on at school after 16. If, as Marmot says, life chances and opportunities are an important part of people’s well-being and health, how can the Minister explain the contribution of this initiative to public health?

I want to turn to the regulation of tobacco. This House has debated this issue at length and over quite some time, and by several large majorities it supported the introduction of point-of-sale tobacco regulation and the banning of tobacco products in vending machines. Just this morning, on the “Today” programme, the Secretary of State confirmed that he accepted the evidence that the visibility of cigarettes is a factor that leads to the initiation of smoking. He also mentioned the issue of plain packaging and the Government’s intention to consult on this. We all know that such a consultation will take years and that any action to put tobacco into plain packaging, following on from such a consultation, will take years to come into force. This cannot and should not be seen as an alternative to the legislation to ban tobacco displays. The display legislation is on the statute book. It will protect this generation of children from brightly coloured displays in shops. I should like to ask the Minister this: will cigarettes no longer be on display in supermarkets from October next year? Further, if the Government intend to consult on plain packaging, how long will the consultation take, who will run it and how much will it cost?

I have two or three more questions for the Minister. I warmly welcome the Government’s intention to invest in Sure Start children’s centres and in more health visitors. I also support the development of health protection plans and screening programmes, but I have to ask the Minister: is this nudge or is this target? How are the Government going to decide whether enough people are being screened, because that aim needs a target rather than a nudge? The ring-fencing of public health budgets is going to be a challenge. How will the Government decide what is going to be included in those budgets and what will be excluded? Moreover, how are they going to stop hard-pressed local authorities from raiding them? That will indeed be a challenge. We support the Government in doing this, but we will need to address how it will be possible to deliver that ring-fencing.

Finally, I certainly welcome the greater use of voluntary and community organisations. We worked with many organisations in different health fields, and that is exactly right. However, the funding and support for these organisations needs to be maintained.

My Lords, I am grateful to the noble Baroness for the welcome she has given to at least certain elements of the White Paper, and I join her in expressing the hope that this is an area where we can work across the parties. That is because, as the White Paper says, this is very much a matter for all citizens and all elements in society, including industry and employers as well as parliamentarians. However, she asked a number of questions and made several criticisms, so I shall endeavour to reply to as many as I can.

The noble Baroness started by saying that she feels that the White Paper is a little short on strategy. I do not share that view. It makes it clear that we are making a conscious shift of power to local government to draw together public health with the factors that are so influential in achieving good health outcomes. Examples of those factors are housing, transport and education. It is about simplifying, strengthening and unifying national arrangements to reduce red tape and duplication, and to have a clear focus and high priority on public health within central government as well. I believe that the strategy is clear and I hope that, when she has had time to read the White Paper at leisure, she will modify her view.

She referred to the Health Protection Agency and she was right to say that the functions of the agency are, if Parliament agrees, going to be subsumed into Public Health England. The new body will bring together key professionals involved in public health from the national to the local level. It will have a mission to protect and help improve the nation’s health and well-being.

She asked about directors of public health in the new system. With the abolition of primary care trusts, directors of public health, employed by local authorities but jointly appointed with Public Health England, will be responsible for commissioning health improvement and some health protection services using the ring-fenced budget to which I referred. We envisage that, through local partnership working, including through the local health and well-being board, directors of public health will be able to influence the wider determinants of health and well-being and improve outcomes for their local population.

The noble Baroness was sceptical about the concept of “nudge”. The Government’s approach to health improvement is not based solely on nudging people. We accept that the evidence base for applying insights from behavioural science and health contexts is relatively undeveloped. That means that we need to develop the evidence base for that approach, clearly, and that we need to use a wide variety of methods to encourage people to adopt healthier behaviours, not just based on nudges but by continuing to use other effective approaches, such as customer insight and segmentation. As the Statement mentioned, there will always be a role for regulation. However, the Nuffield ladder, which the noble Baroness will see in the White Paper, gives a very good illustration of the menu of options available to us in this context.

The noble Baroness referred to schools, and I note her concerns. At the same time, we have plans for developing the use of school nurses. I see that as a very important part of the vision to ensure that we can have a workforce that is alive to public health issues in the school context. A great deal of work is going on, and I would be happy to brief the noble Baroness on that.

She referred to tobacco, an issue to which we regularly return. I have little, I fear, to add to what I told the House during the Question earlier this afternoon. However, we are considering plain packaging, as I mentioned earlier. The current intention is to ask retailers to cover up their displays of cigarettes so that children are not attracted by the packaging. This is widely accepted as the last form of marketing available to tobacco companies to recruit new smokers. We also want to look at how plain packaging could further protect children from taking up smoking in the first place, and help support people who are trying to quit. It is early days. We cannot say more than that at the moment, but it is something to which I am sure that we can return. On tobacco displays, I cannot add to what I told the House earlier this afternoon. This is still under consideration.

I am glad that the noble Baroness welcomed the concept of the ring-fenced budget. Local authorities will be accountable for the use of the budget. We expect that directors of public health will take the lead in local authorities on the use of the budget. We will be clear about the outcomes that we are seeking, but we will not be prescriptive about how those outcomes are achieved. I think that there will be transparency about the use of the budget through the normal, local, democratic means. More details on the accountability arrangements will be set out in the public health funding and commissioning consultation document, which will be published very shortly.

Finally, the noble Baroness asked me to clarify how we viewed the system as being joined up. We do, I think, view this as potentially a joined-up system. Successful delivery of public health services will require strong links not only from Public Health England at the centre with local authorities, but also between local authorities and the NHS. Joint working will be essential in supporting the collection and provision of the information needed to inform future commissioning, and to enable specific public health services to be commissioned through and delivered by the NHS. That will require a sharing of expertise and knowledge across the two services.

I look forward, as I hope the noble Baroness does, to a new public health effort. We will doubtless return to this topic when, in due course, the health and social care Bill reaches this House as there are important measures in it on which this service will depend.

My Lords, no one who has listened to and observed noble Lords on the Front and other Benches opposite would think other than that they are passionately committed to the health service and to the health of the nation. However, as they look back over the past 13 years, they would also observe that at the end of that time issues such as obesity, smoking, sexually transmitted diseases, mental health and the increasing disparity in morbidity between people who live in poor areas and better-off areas were uncompleted in terms of what they wanted to see. It therefore does not seem unreasonable to ask whether that was partly because the approach had reached the limits of its validity.

That is why, in welcoming the Statement, I ask my noble friend to address two brief questions. First, as we move towards more local responsibility for provision of public health, and the undertaking of that responsibility by local directors of health and local health and well-being committees, is there a recognition that that transition cannot happen without real input and help from Public Health England and from those experienced in delivering public health? It cannot be adopted at the drop of a hat. Secondly, when it is adopted—and different approaches will be taken in different areas, quite properly and, in many ways, more effectively—is there a recognition that Public Health England will also have a role in liaising with and providing a network among the directors of public health and health and well-being committees so that they can promote health in the way that we all want?

I remind noble Lords that we have a very short amount of time and that they should be extremely brief, either with a question or with a comment. They can do either but they should be as brief as possible. I shall try to be as fair as possible in getting around the House.

My Lords, my noble friend asked a series of important questions. He has put his finger on how, in many senses, the system will be joined up. He is right to say that Public Health England will be instrumental in supporting local directors of public health in their task. We envisage that Public Health England will create a common sense of purpose and values among a widely dispersed group of workforces. We will develop a workforce strategy with representative organisations and publish that next year. That, I hope, will help to support a smooth transition. At the same time, we do not want to cramp the style of local directors of public health. Much will be down to local decision-making and, in particular, the individuals now employed in PCTs will be looking to transfer across to local authorities as the size and shape of public health teams materialises over the months ahead. We are not going to prescribe from above in determining how public health teams should be configured in local authorities, but there will be considerable support in the advice and expertise available from the centre.

There is much that is welcome within the report but I have some reservations. When the directors of public health are employed by local authorities, will the local authorities also be responsible for their appraisal? Who will be responsible for their revalidation? Will there be audits of the impact of any interventions? Will there be co-ordination of those audits to see which interventions are the most effective? Will there be research in public health to find the most effective ways of guiding people’s behaviour so that they contemplate change? The word “nudge” has been used in the Statement. This goes back to Julian Tudor Hart’s work, many years ago, highlighting the inverse care law. It will be really important that directors of public health do not become isolated in a local authority where they find it difficult to bring about change.

My Lords, the noble Baroness will see when she has a chance to read the relevant section of the White Paper that local directors of public health will be jointly appointed by Public Health England at the centre and by local authorities. We see that as important because they will be fulfilling multiple roles. For example, the health protection role fulfilled by Public Health England will have to be delivered at a local level and, to that extent, it is important that directors of public health are accountable upwards to the centre. At the same time, in much of their work, particularly on health improvement, local directors will be accountable to their local authority and their local population. There is a dual accountability working here.

On appraisal mechanisms, I think it is too soon to say, as we have not worked out the detail of that, but clearly, that will have to reflect the dual accountability I mentioned.

On the audit question, we are issuing a paper about the outcomes framework. The way in which outcomes are assessed and audited will be key to ensuring that the interventions and initiatives that are put in place are evidence-based, that they are relevant and that they have an effect. I hope that the noble Baroness, for one, will feed into that consultation.

Finally, the noble Baroness asked about research. There will be two main engines for public health research. One is the NIHR school for public health research, which will consist of leading academic centres of excellence focusing on evaluation and what works practically and can be applied across the whole country. The other will be the policy research unit on behaviour and health, located in the department, the opening programme of which will initially focus on four behaviours; namely, diet, physical activity, smoking and alcohol consumption. It is very important that we get closer to what motivates people to change behaviour.

There is much to welcome in the noble Earl’s Statement and I agree with my noble friend Lady Thornton that there are some things to be concerned about. We should be careful that nudge does not become fudge in respect of the implementation of these policies. My question relates to the very substantial reductions in teaching grants to our universities. Has anyone in Government yet done any work on or given any thought to the implications of the reductions in those grants for the training of doctors, dentists and other paramedics in our higher education institutes and other colleges? If they have not, they should do so quickly, because the implications of those cuts could have a very substantial bearing on the number of doctors, dentists and others coming out of our universities in the future.

My Lords, the training of the workforce will be key—I would not disagree with the noble Lord on that question. This is a matter on which we are focusing very closely. I will need to write to the noble Lord on the specifics of his first question because the figures are not in my brief, but we are clear that, without the necessary workforce to deliver the public health programme on the ground at local authority level, we will not be able to see the improvements that we need. That will be a major focus for my department.

Does my noble friend recall in “Dr Finlay’s Casebook” the role of Dr Snoddie, the very independent but suitably qualified director of public health, for want of a more modern phrase? When my noble friend comes to look at the qualifications for directors of public health, will he ensure that they have the appropriate qualifications, so that we do not repeat what has happened elsewhere in the health service, with a generation of administrators who override the clinical judgments of those who are more medically qualified to take decisions?

My noble friend takes me back to happy days watching “Dr Finlay’s Casebook”. I seem to remember that Dr Snoddie always had an encounter with Mistress Niven, who came down with all manner of complaints and ailments that the redoubtable duo usually diagnosed and dealt with.

My noble friend is correct. We have to ensure that we have the right people trained at the right level to deliver this service and that we do not get bogged down in managerial bureaucracy. Health and well-being boards will be a vehicle for public health, social care, the GP consortia, when they are formed, and the patient organisations, such as HealthWatch, to come around the same table, so to speak—maybe literally—in order to look at the broader health needs of an area and decide on priorities. I see that as powerfully playing into the public health agenda. This will be far from being a process that is bogged down in bureaucracy.

My Lords, I welcome this document as well as the concept of cross-party working on public health services. I particularly welcome, as the Minister might expect me to say, the references in the document to improving sexual health.

I have a number of questions. On the directors of public health, the Minister talked about them being at the right level. What level is that expected to be within the framework of local government? Unless they have a high status within local government then, unfortunately, they might not be able to influence some of the things that they might want to influence. I have another question regarding the directors. In working with GP consortia, what if there is a difference of view that needs to be resolved? Who takes the final decision? Who has the final say in respect of that?

How is it going to be determined whether an area qualifies for the new health premiums? With regard to ring-fenced budgeting, the aid support grant lost its ring-fencing. Does that mean that it will be in the public health ring-fenced budget or not?

When the independent advisory group on sexual health, of which I was chair, was abolished, we were told that a new sexual health organisation would be established. What will be the process for that and when is it likely to happen?

My Lords, the noble Baroness asked me a number of questions there. I may not be able to answer all of them now, but I will certainly write on those that I cannot.

As I mentioned earlier, it is important to recognise that in part the status of directors of public health will be confirmed by virtue of not simply being appointed locally, but also by being appointed from the centre by Public Health England. That will confer an added status to them. With the dual accountability that I referred to, primary accountability would be to their employer, the local authority, but the Secretary of State would have a backstop power to dismiss directors of public health on the basis of a failure to discharge local authority responsibilities in the area of health protection. Again, while one does not want to dwell on that power, it signifies that this is a person who will be there very much as the representative of the Secretary of State.

The noble Baroness asked what happens if there is a difference of view. Differences of view will arise but the important point to emphasise here is that we want to see them sorted out at a local level wherever possible. That will not always be possible but it should be the aim that health and well-being boards and consortia should decide, in the light of the joint strategic needs assessment and other factors, what the priorities are locally and how the budget is to be spent. It has to be that way: second-guessing from the centre is bound to lead to perverse consequences. However, there will be mechanisms available to ensure that the NHS commissioning board will have a role in trying to resolve these issues and the noble Baroness will see, when we publish the health and social care Bill, that the Secretary of State will have a backstop power in extremis.

She asked about the health premium. We will be publishing a document for discussion on this. We want to hear the views of everybody as to how this should work. Clearly, if a health premium is paid it has to reflect a measure of genuine progress in reducing health inequalities, while recognising that some areas start off with the handicap of having particularly deprived communities to work with and that the task is thereby more difficult. It is important that the department receives the views of interested parties to see how this is going to work.

On sexual health, we are looking to see what more can be done to increase the awareness of risks, prevent infection and promote access to screening and treatment. The consultation documents, which will be issued shortly, will set out the proposed funding and commissioning routes for public health services, including how comprehensive sexual health services might best be commissioned. I hope the noble Baroness will feed into that.

My Lords, the noble Earl mentioned looking at the causes of the causes very early on in his Statement. I think it is now well accepted that a foetus is not protected by either the placenta or the blood-brain barrier from environmental assaults. I am concerned that a lot of the obesity that we see now in young children who run around normally and cannot be described as couch potatoes—although perhaps their diet is deficient—may have originated in the womb from oestrogen-mimicking hormones and by chemicals such as bisphenol A and phthalates. It seems to me that we disregard these factors at our peril and we are blaming people for factors that are beyond their ability to control. Another point is the effect of maternal stress on the foetus. High cortisol levels in the mother affect the child and cause ADHD and educational problems later on in their lives. What is the Minister doing to look at what is happening to babies in the womb and the effects on them in their future life?

I shall need to write to the noble Countess on exactly what work programmes are in train in that area but she is absolutely right—this is an area that I have taken a close interest in over the years. It is fundamental to understanding both health in childhood and later on in adulthood, and behaviour in children.

We fully recognise that good nutritional status is important at all stages of life. That includes the role of the diet in pre-maternal health, and affects teenagers in particular and the elderly, where there are concerns about malnutrition; I know that is not the focus of the noble Countess’s question. The national diet and nutrition survey will allow us to continue monitoring the status of the diet in the UK population and to target interventions where they are needed. I will write to the noble Countess to give her further particulars.

My Lords, could my noble friend please explain one tiny inconsistency in government policy? Today he announced that some parts of NHS expenditure would be ring-fenced to deal with the problem of obesity. However, earlier in the week the Education Secretary removed ring-fencing on school sports, which was partly designed to tackle the same problem. Am I right about this being an inconsistency, or can my noble friend explain whether I am making a mistake?

Far be it from me to say that my noble friend makes mistakes. No, he has not misunderstood the situation. The point of the ring-fence is to ensure that the money we supply to local authorities is genuinely used for public health purposes. That is obvious. However, there will be flexibility for local authorities to decide what falls within the public health definition. As long as they can justify their decision that the expenditure is public health-related, they will be free to spend the money accordingly. There may be uses for public health money that involve schools or sport and so on. This, again, is something that we will need to look at when we define how much money there will be—that is being worked out—and in our dialogues with local authorities, to ensure that the rules are absolutely clear.