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Inquiry into Participation in Sport and Physical Activity in Northern Ireland — British Medical Association

4 March 2010

Members present for all or part of the proceedings:

Mr Barry McElduff (Chairperson)
Mr David McNarry (Deputy Chairperson)
Mr P J Bradley
Lord Browne
Mr Trevor Clarke
Mr Billy Leonard
Mr Kieran McCarthy
Mr Ken Robinson

Witnesses:

The Chairperson (Mr McElduff):

I formally welcome the representatives from the British Medical Association (BMA) to the meeting. It is a three-person team comprising Dr Tohani, Dr Nugent and Gráinne Magee.

Ms Gráinne Magee (British Medical Association):

I thank the Chairman and the Committee for inviting us to give evidence to the inquiry. We very much appreciate the opportunity to give evidence from the perspective of doctors. The BMA is very concerned about the problems that Northern Ireland faces, which are common with those in the rest of the UK, as a consequence of a combination of poor diet and a lack of exercise.

The British Medical Association has a long-term interest in the health of the public and believes that the most effective way to improve the population’s health is to improve activity levels among inactive people. Despite the clear benefits of regular exercise, the Northern Ireland population is mainly sedentary. Activity levels have declined in the past 30 years, and the majority of children and adults in the UK are not physically active.

However, the evidence demonstrates that an inactive lifestyle has a substantial negative impact on both individual and public health and is the primary contributor to a broad range of chronic diseases such as coronary heart disease, stroke, diabetes and some cancers. The high level of individual suffering caused by those diseases, together with the substantial associated financial costs, makes this a major public health issue. However, at the outset, we want to say that tackling levels of physical inactivity requires a cross-departmental and cross-sectoral approach, and we encourage government Departments to play their role.

Dr Theo Nugent is a practising GP and a member of the BMA council. Dr Vinod Tohani is also a member of the BMA council and is an independent public health consultant.

Dr Vinod Tohani (British Medical Association):

Thank you for inviting us. As we have already highlighted, physical activity not only contributes to well-being but is essential for good health. The evidence is compelling. Our submission highlights some of the benefits of exercise; I will quickly repeat some of those.

The great majority of adults in Northern Ireland do not participate in physical activity at levels that provide the full range of public benefit. It has been agreed internationally that a minimum of 150 minutes of exercise a week is essential ― 30 minutes a day for five days ― to provide any benefits to an individual’s health. The Chief Medical Officer highlighted that point in his report, ‘At Least Five a Week’. An increase in activity levels would contribute to the prevention and management of several conditions, such as heart disease, diabetes — particularly type 2 diabetes — and some cancers. Moreover, it would have a beneficial effect on mental well-being and an overall impact on weight management.

People who are physically active reduce their risk of developing major chronic diseases, having a stroke and contracting type 2 diabetes by up to 50%. An active lifestyle can also help people to cope with the feeling of stress and improve their mental well-being, and an increase in activity levels has beneficial effects on muscular and skeletal health, particularly in elderly people with osteoporosis. Regular exercise certainly delays osteoporosis in women.

It is recognised that the fundamental cause of obesity is a lack of physical activity. Obviously, many other factors, such as diet, contribute to obesity. In Northern Ireland, 59% of adults are obese, and about 26% of children are overweight or obese. Worryingly, data from the Northern Ireland child health system in 2004 and 2005 indicated that 22% of children in the Province are obese. That leads to other chronic medical conditions later in life.

In terms of physical activity, the Northern Ireland health and social well-being survey found that only 30% of adults in Northern Ireland meet the 150-minute criterion. Therefore, 70% of people are still inactive or do not take enough exercise to be beneficial to their health. The costs of inactivity are immense. Obesity and type 2 diabetes can lead to 2,100 deaths per annum in Northern Ireland. That situation could also be modified by increased activity levels.

The reasons why people are less active are multifactorial. If you look at history and the way that society is going, you see that more and more people are travelling by car and work is becoming more or less automated. Therefore, people’s physical activity levels at work or at rest are limited. There are several barriers to physical activity; for example, social and environmental barriers, such as lack of playgrounds and parks near where people live, and house design. There are also personal variables: people who have not been involved in physical activity as children find it hard to get motivated or to change their behaviour as adults.

Given that there are multiple barriers to participation, a number of policy interventions are required, rather than a one-size-fits-all solution. Changing inactive lifestyles and activity levels presents a tremendous public health challenge. There is evidence that public health action on a number of levels helps to increase people’s physical activity. That is a long-term challenge. The complex and social implications of that challenge call for long-term efforts and investment. That includes policy and environmental changes; development of strategies, such as local transport plans; involvement of primary care; and targeting of different groups — in particular, getting the message to lower socio-economic groups. While middle socio-economic groups may take part in more exercise, the message is still not filtering, for various reasons, to lower socio-economic groups. Either the environment is not apt for those people or our message is not getting to them as it should in order to inform them and to change their behaviour.

At government level, all Departments have a role to play in planning and working with education providers and the health and leisure industries. Indeed, they have a role in planning future housing, parks, road services and transport policies. All of those need to be integrated in order to impact on people and change their behaviour.

As regards employers and workplaces; the Health Service is the biggest employer in Northern Ireland. However, its priority has not really shifted towards encouraging staff to take adequate exercise or to cycle or walk to work. In order for staff to do those things there must be environmental changes to buildings, such as provision of showers, so that people who come to work by bicycle can shower and change their clothes if they wish. Therefore, many things must be integrated in order to encourage people at employment level.

As regards schools and colleges, I have done little research on the curriculum. Sport and physical activity is built into the school curriculum. However, I have no knowledge of how well schools actually incorporate that and motivate children. That must be examined. In other European countries and in America, governments look at the effectiveness of sporting activities in schools and, particularly, at children who do not take part in them.

As regards leisure and sports services; again, consideration must be given to the design of leisure centres, their distance from users, and whether transportation is available. What are the charges? It is almost impossible to ask to encourage an unemployed person to fork out £5 to travel to the facilities and another £5 to take part in an activity. The cost of using leisure centres and sports centres needs to be looked at.

Even America, which is a capitalist society, encourages communities to use school sports centres and gyms after hours, because schools get the money to build those facilities from the taxpayers. Obviously there needs to be some investment in terms of paying for security and the locking up of those facilities.

Dr Theo Nugent (British Medical Association):

As I wandered around the premises this morning I was struck by the number of dangerous items that are scattered about the place as demonstration pieces. However, nowadays, the seats that we are sitting on are possibly the most dangerous items, because they lead to complacency as we sit in our offices gazing at computer screens. That has a cumulative effect and increases the number of hours that we spend doing nothing other than moving our mouse hand.

As Dr Tohani said, GPs see the end results of inactivity and lack of exercise in society, which include heart disease, diabetes, strokes and all the factors that accompany stress. Less predictably and more surprisingly, perhaps, three of the biggest killers — colon cancer, breast cancer and lung cancer — are definitely reduced by increased exercise exposure. Older people, who constitute a large number of primary care consultations, can also benefit, not just from lifelong exposure to exercise, but from exercise in later life that can augment bone strength, mobility and balance. Alongside that, but just as important, is the social and mental well-being that goes with regular exercise, particularly in group environments.

GPs find it difficult to motivate people to exercise. It is hard to set the time aside, and, ultimately, as with most other risky activities, it is a question of how scared the individual gets. That is what it boils down to in a consultation. Preaching and lecturing to a patient is of no use, and is disrespectful anyway, but if a patient comes in with genuine concerns, I am there to try to quantify the risk to that person as an individual and to let them make an adult, grown-up decision to motivate themselves to do something about their condition. If it is appropriate, I will signpost them in certain directions.

We often see advertisements on television or in other media that tell people to consult their GP about taking up exercise. It should be the other way round: they should tell people who are not exercising to get a letter from their GP advising them to sit down for six or eight hours a day and stare at a TV.

We are keen to lobby for proven interventions, not just in the consultation environment but in a broader community sense. As Dr Tohani said, it is often the simple things that make the difference. If you cycle to work, where do your store your bike? If you store it somewhere dodgy you can come back and find only the frame there. You can get more exercise carrying the frame home to get new handlebars and wheels, but that is a one-off manoeuvre. [Laughter.]

I was struck, reading some of the papers, to find that dress code at work is an issue. To dress as we are today, very elegantly and neatly, does not lend itself to cycling or jogging into work. I am not saying that we should arrive to work dressed in Lycra. [Laughter.] I would clear the surgery in 10 minutes or less.

Education, in the classical sense, is very important, and that goes back to the interdepartmental aspect of the issue. It is about motivating children to exercise and getting them used to it. I was struck by a paper from Finland, where they have the concept of a joyful model of sports schools teaching for 4- to 13-year-olds. I asked myself how joyful my sports education at that age was. It was not; a tiny minority of us rushed about and had great fun, but most did not.

Children can have a tremendous enabling role in the family. If the kids are coming home buzzed up about simple exercise activities, such as walking to school or walking in the park, it can have an effect. I do not mean high-end stuff, such as gym membership and high-impact sport. This is basic stuff, and it is a great lever for change. Much the same happened in the lobby against smoking. Kids were the single most effective activists that we saw in primary care. Parents arrived in the surgery and, whether it was an excuse or a reality, they said that the kids were giving off that mummy and daddy were smoking and that something horrible was going happen to them. That is often why parents presented themselves at surgery.

One other aspect that has surfaced in my reading is the whole concept of exercise on prescription. Initially, I thought that it was a good idea, and that we should give patients dockets which they could bring along to the leisure centre and do some training-room induction or get subsidised swimming or something. However, the evidence that that works is pretty ropey. If there is a one-to-one arrangement, where a personal trainer mentors an individual for weeks and months, maybe you will get through to patients — by which I mean that they will be supported to achieve their aims. However, one study showed that, for every 17 patients referred for exercise, only one carried the course through to its completion and continued exercising. Presumably, those were people who raised the issue during consultation or seemed amenable to the idea.

I then made the further mistake of contacting a few of my GP colleagues to ask about their experience of the various local initiatives, which, on paper, have been very noble and logical. I was taken aback by the negative feedback I received from my colleagues. They were not cynical or dismissive of the process. Far from it; they would love to find a solution to all the health downsides that go with lack of exercise. However, patients — and all of us in this room, me included, are patients — do not stick with things. It is very difficult to maintain motivation unless there is a broad social thrust in that direction.

We will probably talk, in due course, about other countries and areas where there have been successes. Perhaps that is the territory that we should be staring at right now. We must ask ourselves how we can pick the best practice used in other places which does not cost a lot and yet can motivate us all to exercise.

The Chairperson:

Thank you for the presentation. I am going to bring in the Deputy Chairperson in a wee second. I recently saw a bicycle shed at a government building, at which there were no bicycles but which was used as a smoking area. [Laughter.]

Mr McNarry:

Where was it?

The Chairperson:

I said that I was going to bring the Deputy Chairperson into the discussion. I point no elbows at him.

Mr McNarry:

You have a very shallow life. Are you going round looking at these bicycle sheds? What else would you do in a bicycle shed?

The Chairperson:

I was stunned.

The Committee could look at how many government Departments are taking up the bike-to-work scheme. I am told that very few government agencies, including health trusts, encourage their employees to cycle in that way. We should investigate that.

Mr McNarry:

I would normally have been behind the bicycle shed; that is part of growing up. However, we will leave that for another day. It might affect my health in later years.

I listened to what you all said, and thank you for your professional approach to this. Dr Tohani mentioned the school estates. I have a private Member’s Bill sitting with the Education Department. That is what it is doing, sitting. It proposes the opening up of school sports facilities after hours, during holidays and so on. In that way, we could take advantage of implementing good healthy leisure programmes. That Bill has now advanced to a working group, which is preparing a report for the Minister to try to take on board its ideas and others. Are you aware of that working group?

Dr Tohani:

No, I was not actually aware of it. However, I undertook my early training in the United States, and the schools there are used after hours for community purposes.

Mr McNarry:

It might be interesting if I was to make the BMA aware of that group and the details of who is handling it. The BMA’s input would certainly help.

Moving on, much has been made of cuts in funding and particularly the extensive reduction in the health budget. How do you envisage those cuts impacting on those programmes that have been, or will be, designed to combine sport and healthy living?

Dr Tohani:

The current problem with obesity is not going to go away, and it must be addressed through the provision of health services. Any initiative undertaken in that area will have a future benefit in reducing some of the health funding requirements. Over 30% of people are currently obese. The associated chronic diseases linked to that obesity will also not go away, and we will require healthcare funding to support the current level of activity.

There will be a future dividend if we start investing now. However, if we do not do that we will require even more money in the next 10 years to address these issues. What we do now will help us in the next 10 years.

Mr McNarry:

That is a very important point, and very helpful to what the Committee will include in its report on the inquiry. Where funding is concerned, the priorities are the devil in the small print. From the evidence that we have taken so far, we can see that there is something that sport can contribute to the obesity problem. Has the BMA made representations to the Department of Culture, Arts and Leisure or the Health Department to highlight its concern that obesity should be treated as a priority? If you have, how have you got on?

Dr Tohani:

The BMA has continually highlighted the shortfall in the funding of health services and asked the Government to ensure that adequate funds are in place to provide the current level of service, let alone any future issues that will be encountered. We need more money in the Province to tackle some of the health issues that we already have. The BMA has been very clear in its thinking in that respect.

Mr McNarry:

Are you saying that if we do not address the problem of obesity now, we will require a great deal more money when, and if, that money becomes available in the future?

Dr Tohani:

If we do not address the problem of inactivity now we will certainly require a lot more money in the future.

Mr McNarry:

Will the BMA supply the Committee with some facts and figures on that?

Dr Tohani:

We can certainly look at what will happen if the levels of obesity continue at the same rate.

Mr McNarry:

It is a significant thing that you are saying, and it is all very well for the Committee to hear you saying it. However, I would like to see it backed up with some evidence that the Committee can include in its report.

Dr Tohani:

We will try to get you some figures on that.

Mr McNarry:

If you could change government policy, what one thing would have the biggest impact on increasing participation in sport and physical activity?

Dr Tohani:

We should concentrate our activities on young children as a priority grouping, and ensure that they are taking part in an adequate level of exercise and sports activity. That will have a beneficial effect on their health.

I asked my colleagues what one action could be taken to improve the situation. In England, there is a problem with school playgrounds being sold to property developers. Therefore, one action would be to stop selling those grounds to private developers.

Mr McNarry:

Does that include golf clubs? [Laughter.]

The Chairperson:

Thanks very much, David.

Mr McCarthy:

That is an interesting question that we could talk about.

Thank you for the presentation. You said that half an hour of exercise a day would be sufficient. I am a keen cyclist and spend two and a half or three hours in the saddle on Saturday and Sunday. Does that make up for not doing exercise during the week?

Dr Tohani:

You can divide the half an hour of exercise over the course of a day. For example, you can have a brisk walk for 10 minutes, three times a day, or you can go swimming. There are a multitude of things that you can do.

Mr McCarthy:

So my three hours on a Saturday and Sunday will keep me going all through the week.

Dr Tohani:

No, exercise should be on a regular basis; at least five days a week.

Mr McCarthy:

Does the BMA have any information on other regions — you mentioned Finland — that are doing the thing right and from whom we could learn?

Dr Tohani:

There are a number of things. We have looked into what other regions are doing. For instance, the Polish Federation of Food Industry and the chief sanitary inspectors have a keep-fit programme in almost all Polish schools.

Denmark has a programme for testing aerobic fitness in schools, under the aegis of the Danish Heart Foundation. There is a programme in the East Midlands that provides a platform on food, physical activity and health. The University College London centre for transport studies is researching and trying to understand children’s play and the role of physical activity. There is a European association of private catering companies which promotes healthy lifestyles in the workplace, including physical exercise.

In the US, the National Institute on Aging gathers important evidence on the value of vigorous activity in old age. That is a very important area, because people are living longer. When you hit 40, you should not stop exercising; there are many benefits of exercise in old age and for those who are physically disabled. Therefore, there are a number of things going on in the world that we can tap into.

Mr McCarthy:

It is important that we learn from the examples that you quoted and others.

Dr Nugent:

There are a couple of specific ones that I have picked up on. The example set by the Finns is quoted extensively; they have good evidence to show that their initiatives have made a difference. In one of the papers I read, I was struck by the fact that they did lots of scoring of people before and after exercise programmes. One of the analysis scales that they used was called the “cynical distrust scale”, which was a wonderful name. [Laughter.]

The Finns have it in legislation that there must be interdepartmental discussion about any new development of whether it will have proper access, such as walkways and cycling areas.

The Canadian approach is also very impressive. The Public Health Agency of Canada website has information on exercise and physical activity for all age groups and all types of people; it is not just for athletes. It provides excellent examples and vignettes of what individuals can do, as well as very useful links to other organisations. It would be well worth looking at that website.

Dr Tohani:

There are some other examples. The principal of an integrated school in Armagh asked parents to drop their children at the end of the road so that they can safely walk up to the school, which is about a quarter of a mile. That is a good practice. I asked how effective the programme was. I was told that the middle classes used it well but that parents from the lower socio-economic groups still drove right up to the school to drop off their children. The message must be targeted to all members of the community rather than simply to people who are better educated, who may be more likely to take advantage of the message. We must consider how people who are disadvantaged can be encouraged to take up the message.

Mr K Robinson:

I was going to ask what governments can do to encourage more people to start walking and cycling as a means of transport, but you have answered most of those questions.

You have brought me on to the topic of culture, which is what I really wanted to ask about. You mentioned Finland; the culture there is homogenous, and the people tend to do what government and society wants. We are a disparate culture and, if we are told to do something, we will do the opposite.

You talked about the importance of healthy diets. Children may have a healthy diet in their primary schools, but, if they live in one of the socio-economic districts that you described, they might pass a Chinese restaurant, an Indian restaurant, an Italian restaurant, a Subway-type thing in a petrol station and any other type of food that you can mention. All of that unravels what the school has done. How do you, as medical professionals, get the message across to society, including parents and businesses? Steps have been taken to deal with tobacco, and I feel that we are moving towards steps being taken to deal with alcohol. There is no sense in curing those two problems if we are stuffing our kids full of fast food at an early stage in their lives.

Children do not get the physical opportunities that you would like them to have. When I was a schoolmaster, I was able to provide those opportunities, but schools are now under such pressure that cuts have to be made somewhere. The children spend half an hour getting ready for PE and another half an hour getting sorted out and back into class, so it is easy to say that it should be scrubbed in favour of maths or something else.

How do you get that cultural message across to us as administrators and legislators, to the parents, to the schools and to the business community? Fast-food outlets and off-licences are not located on the Malone Road or in the other salubrious areas of Belfast. They are right in the heart of the communities that suffer already from social disadvantage. What are you going to do for us? Is there a way out of that maze?

Dr Nugent:

It is not easy, and there is no one-size-fits-all answer. Addressing the problem relies on the entire range of services. One cannot stop advertising and fast-food outlets, and one cannot legislate against some of the things that you mentioned.

Mr K Robinson;

Alcohol and tobacco have health warnings. Do we need to start putting health warnings on certain types of food — other than the little ones in the small print that I cannot read?

Dr Nugent:

Health warnings might also be required for cars and lifts. A good example is that a GP colleague gave exercise prescriptions to two patients who then walked out of his office and took the lift to the ground floor. The issue is so basic, yet what can be done about it? It goes back to education and challenging some of what we take for granted. As Dr Tohani said, simple messages such as walking an extra quarter of a mile to school are important. That can involve escorted walks from school to the bus depot, rather than the children being picked up at the front door. All of that will happen by a drip feed, rather than by gigantic leaps.

Mr K Robinson:

Where does the pressure come from? Is it through you, the medical profession, or is it through us, the politicians? Is there some other part of society where that thrust has to begin and be sustained?

Dr Tohani:

It has to be an integrated approach, not telling schools to introduce more physical activity when they do not have the equipment or an area in which those activities can take place or the roads are not safe for children to walk to school. In one study, parents were asked why they do not let their children walk to school, and many of them said that they were worried about their safety because of the traffic and the way that they have to cross roads and the school’s location. We need to look at all of those areas; there is no one thing that will not address this. It is about giving the knowledge to people and empowering them and taking on board their views on where schools should be located and what services need to be developed. I am afraid that at present, we tell society what is good for it, rather than it asking. If demand were built from the bottom up, more people would respond to the challenge.

Mr K Robinson:

I just want to challenge a point what you have said there. Craigavon is a planned city that has walkways and cycle ways. Unfortunately, the Committee does not have a member from Craigavon at the moment. From a public safety point of view, I wonder what the uptake is of regular use of those walkways and cycle ways. I suspect that it is fairly limited.

Dr Tohani:

I actually lived in Craigavon. I was a good socialist and I always wanted to live among the masses. [Laughter.]

Mr K Robinson:

You could be walking us into trouble.

Dr Tohani:

The thing is that, although it has cycle ways and walkways, they are too far away from the shops. The shopping precinct is a recent phenomenon. Prior to that, there was nothing. You might as well have been living in a Third World jungle somewhere when the city was designed initially. There was no regular bus service in Craigavon at that time. When people were encouraged to move there, they did so because they were getting paid. When they had spent the money, they took the plumbing with them as well. In a way, you cannot blame those people, because neither society nor the community were ever involved in the planning of the city. That was done from the top down. It looked wonderful to the planners on a piece of paper. However, I do not think that much thought was given to the people who would live there.

Lord Browne:

Your presentation has succeeded in making me feel a little guilty about my lack of exercise, at least for a little while. I am the right person to ask this question. Your submission does not include any details of what advice doctors in Northern Ireland have been instructed to give to patients who are overweight or obese. Do you believe that the advice that they have been instructed to give is adequate?

In Belfast, the Grove Wellbeing Centre has opened. It combines leisure facilities with a medical centre. Do you believe that that sort of place achieves greater success rates than a similarly funded, modern, conventional leisure centre?

Dr Nugent:

To come back to GP-patient consultation; if someone arrives at a health centre who has medical problems that stem from either obesity or lack of exercise, that is relatively easy to tackle. You can address the patient straightforwardly on that issue. When the patient arrives, we check his or her height, weight, body mass index, cholesterol, thyroid function and blood sugar. In particular, we target folks in the over-50 age group with regard to established diseases that develop from their lifestyle. Then, it is a question of trying to see what that individual patient’s actual motivation. We cannot and dare not nanny people. It is highly disrespectful to do that sort of stuff. It loses the patient’s confidence. Certainly, however, you can raise the issue.

At present, through our local and direct enhanced service, practices are encouraged to check patients’ weights and measures, for want of a better term. However, even that simple act raises the issue. Why are they going into the nurse’s room to have their height and weight checked? Why are they being asked to have blood tests? It is because if someone is shown to have a body mass index that is above a certain level, the risk of certain diseases increases. That opens the door to the consultation. Therefore, it is a combination of trying to enlighten patients while, at the same time, very much being guided by them as to what they want.

Dr Tohani:

If an active lifestyle starts in early childhood, it is much easier to keep up. I have seen people who are grossly obese and need surgical intervention, such as banding. Even when people have that kind of condition and you tell them that they must diet and take regular exercise, they are reluctant to do so. They think that the easiest option is to go for banding. Luckily, nowadays, patients are told that they must be motivated in all directions before the procedure can be done.

It is very difficult to change patients’ behaviour when they are settled into a certain mode. That includes me: if someone were to tell me that I should walk for half an hour each day, that would take a great deal of effort. However, if I had been doing it regularly when I was growing up, it probably would not be so difficult.

Lord Browne:

Playing snooker and darts when I was young did not help me. [Laughter.]

Mr McNarry:

I am intrigued by your answer. Perhaps I am missing something with my GP, who has never addressed that with me. In a consultation, there is a time to get in and to get out. My GP has never taken my weight, and never asked me this, that and the other. Thankfully, I do not visit him very often. Nevertheless, there is a flip side to what you say: that GPs are part of a business and that they are time-bound. Is there is an open approach across the board from GPs that should make you aware of what height you are, what weight you should be, where you are going, what you are doing wrong and so on, and that GPs discuss that with their patients?

Dr Nugent:

I could not possibly comment on the interaction you have with your GP. However, yes, there is such an approach. It is best practice; it is preventative medicine. There is lots of evidence to show that intervening makes a difference and will help to reinforce the relationship between GP and patient. For the last four or five years, there has been enhanced funding to encourage practices to provide that. However, it is up to the practice to decide whether to take it on. They may decide that their workload does not permit it.

Mr McNarry:

So it may not be a priority within a practice?

Dr Nugent:

It is up to the board to direct the enhanced service and to provide it, but very often that does not happen.

Dr Tohani:

Quite a few GPs are doing that. GPs will look at the history of any new patients who come to join the practice. They will consider the patient’s history, vaccination history and all sorts of things. For patients of a certain age, they will conduct five-yearly examinations.

Mr McNarry:

That is, as you say, good practice. It would be interesting to know how many GPs do not practice it.

Mr Leonard:

When you were speaking, I was going to ask about GP outreach and what you can do to help. I am more than interested in the coalface. However, the more I listened, the more I thought that it was going to be very difficult. The last conversation added to that.

I am interested in the broader societal thrust of which you spoke. We have investigated it to some extent, but can we drill down a bit more? What picture do you have in your mind of that broad societal thrust? Perhaps I am asking “how long is a piece of string?” I do not want to hear about the interdepartmental work that it will involve; we can all come out with that. Where and how do you think that broad societal thrust can be created? The more I am involved in it, the more practical, simple and straightforward it will be to get people to buy into those three categories and help our cause. You used the phrase, but where, in practical terms, do you see the building blocks of that?

Dr Nugent:

One of the practical areas to look at is sport. We acknowledge that there is a place for elite sport and the hero worship of the local team. However, a blind eye is turned to everyone sitting on their bottoms on the terraces and elsewhere. They do not move unless someone scores.

We need to get the message across. As the Finns say, it is trying to have a positive experience and a feeling about basic exercise. We must keep it simple. When people think of exercise, they think of gym memberships, going to the leisure centre and having to drive half an hour to get there. That is not what I mean. I am talking about going for a walk when you get back from work in the evening; nothing more complicated. We need to get that message across every time an issue surfaces and build it into the debate.

Mr Leonard:

May I cut in there? I do not mean to be ignorant. I am just thinking that, in terms of that simple message, we tend to think that there has to be a message for children of school age, a message for the over-60s and a message for whatever. I am genuinely not fishing for the answer that I prefer. Is there a message for all that can be mediated for different groups in different ways?

Dr Nugent:

If some public-relations type could get across the message that a chair is an extremely dangerous piece of equipment —

Mr Leonard:

I had scribbled down “Ban the chair”.

Dr Nugent:

It should be something along those lines; we should keep it simple.

Mr P J Bradley:

Is PE compulsory in primary schools?

Dr Tohani:

It is a compulsory part of the primary school curriculum. I can only base my information on a conversation that I had with a school principal. Even some nursery schools have exercise programmes.

Mr P J Bradley:

I agree that we should be targeting schools. When I was chairman of Newry and Mourne District Council, my deputy was a small chap, but very heavy. We launched a healthy eating week, and when I stepped on the scales I was told that I had to lose three or four pounds. When he stepped on the scales, the nurse told him that he would have to grow 18 inches. [Laughter.]

The Chairperson:

I thank the BMA team for their presentation and for the engagement. We will reflect on what you have said in the context of our inquiry. We are very grateful.