Official Report (Hansard)

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Inquiry into Obesity

2 April 2009

Members present for all or part of the proceedings:

Mrs Michelle O’Neill (Deputy Chairperson) 
Mr Thomas Buchanan 
Dr Kieran Deeny 
Mr Alex Easton 
Mr Tommy Gallagher 
Mr Sam Gardiner 
Ms Claire McGill

Witnesses:

Ms Tracy Gibbs ) College of Occupational Therapists
Ms Pauline Mulholland ) British Dietetic Association 
Ms Teresa Ross ) Chartered Society of Physiotherapy

The Deputy Chairperson (Mrs O’Neill):

I welcome Ms Pauline Mulholland, a board member of the British Dietetic Association (BDA); Ms Tracey Gibbs, chairperson of the College of Occupational Therapists (COT); and Ms Teresa Ross from the Chartered Society of Physiotherapy (CSP). I invite you to make your presentation, after which members will have an opportunity to ask questions.

Ms Pauline Mulholland (British Dietetic Association):

I thank the Committee for giving us the opportunity to present allied health professionals’ views on tackling obesity.

The Committee’s inquiry is timely, given the new healthcare arrangements and organisations that came into being yesterday. It also gives allied health professionals the opportunity to make a more co-ordinated and robust contribution, not only to tackling obesity, but to addressing a range of related long-term conditions.

On behalf of the British Dietetic Association, I alert the Committee to the fact that dieticians are uniquely qualified health professionals, which is demonstrated in the way in which they assess, diagnose and treat individuals and the wider public with problems that are related to diet and nutrition. Dieticians make a singular contribution to the prevention and management of obesity at all levels.

At regional level, we feel that we can contribute by working with strategic groups in overseeing the development and implementation of a policy on obesity. To date, we have not had the opportunity to do such work; we are involved only at the lower levels of strategy development and would therefore welcome the opportunity to contribute at a higher level. On the subject of commissioning, we can contribute to the design of services to meet patients’ dietary and nutritional needs. We lead on the implementation of obesity and food-guidance policies in local trusts and in education. We support individual patients in the management of clinical obesity, and we also work with communities and voluntary groups on prevention. That is where local people can make the changes necessary that are to tackle the issue.

In our written submission we provided the Committee with a range of examples of preventative measures. We also provided to the Committee a recent British Dietetic Association leaflet outlining the contribution that dieticians can make. Some examples in Northern Ireland are the Cook It! programmes, which are run throughout the Province, the FRESH programme, which is for young adolescents with obesity in north and west Belfast, and Bank Your Smile, which is an oral health project in the west. Those initiatives are designed to deliver the Investing for Health strategy and the Fit Futures strategy in the Province.

The British Dietetic Association considers that the new Regional Agency for Public Health and Social Well-being provides the opportunity to evaluate such schemes across Northern Ireland and to decide which of them to commission to create the best outcomes for the public. For maximum impact, we would like those schemes to be embedded in core services across Northern Ireland.

We are engaged in joined-up working with many other agencies. That is because people other than dieticians have a role to play. We work with education providers, local councils and environmental health officers. We also work with local leisure centres and other bodies that provide physical activity programmes in support of tackling obesity. We established a range of schemes in schools, but given the fact that one meal a day is eaten at school, we must build on those. We must ask what happens with parents and children beyond the school hours.

One of our key roles is the management of clinical obesity, which is a challenge for individuals and professionals. People aspire to lose a significant amount of weight over a short period, and sometimes that puts them off accessing our services. We need to manage such expectations and promote the message that if individuals can be encouraged to lose 10% of their weight and to maintain that weight loss, they can achieve significant health benefits. The evidence shows that a 10% weight loss will reduce blood pressure and cholesterol, improve the control of blood sugar for people with diabetes, and reduce the death rates for a number of conditions. As a result, we may be able to reduce the number of drugs that such patients have to take, thereby reducing public expenditure.

The outcomes from intensive weight-management programmes across Northern Ireland have been well recorded, and we have several examples. Those outcomes are achieved through a combination of dietary advice, exercise and techniques to change behaviour. Thus we aim to alter an individual’s entire lifestyle and to maintain that change in the long term. We do so using supportive practical approaches, such as cookery demonstrations and supermarket tours. That is because people need to get not only advice, but the skills to put that advice into practice.

In order to deliver on the significant agenda of challenging obesity in Northern Ireland, we would like it to be recognised as a disease in its own right. We would also like a regional obesity framework to be established to support the delivery of the agenda across the Province. The Department of Health, Social Services and Public Safety and other Departments can lead by example by implementing schemes that teach people about healthy nutrition in the workplace, for instance. There are many examples of that type of scheme across the UK. Of particular note is a scheme in Wales, through which the Minister of Health and Social Care implemented a charter for vending in healthcare facilities. Our challenge is to extend that throughout the public sector in Northern Ireland, thereby improving individuals’ workplace choices.

Ms Tracey Gibbs ( College of Occupational Therapists):

Thank you very much. I am delighted to be able to speak to the Committee on behalf of the College of Occupational Therapists.

I will discuss a number of the key areas that we identified in our document. Obesity is a significant issue for the many different groups of people with which we work. That includes people of all age ranges in acute-hospital settings and in their community environments and people who suffer from chronic conditions and other co-morbidities that are often associated with obesity. Other groups of people with which we deal include those with mental-health problems and learning disabilities. We also work with wheelchair users, particularly children and younger people.

Occupational therapists (OTs) in Northern Ireland have identified an increased need for specialised bariatric equipment, and we outlined some implications of that need in our written submission. Bariatrics is the science of providing healthcare for our heavier population. On a day-to-day basis, that has major implications for transporting patients in hospital beds, the use of hoists and porters’ chairs, and for the use of seating in hospitals and in the patient’s home. Addressing the need for specialised equipment for that client group is a major challenge that faces therapists.

Although there is a lot of emphasis on the global epidemic of obesity, it is also important to consider the needs of the obese person. It must be ensured that they are treated with respect and dignity and that stigma and discrimination are avoided. A person who is overweight may feel socially isolated or excluded. Their role as a caregiver, as a spouse or as a child, for example, may be affected. As a result, occupational therapists consider the ability of the overweight person to look after themselves and their ability to function in their own environment. Very often, activities of daily life may be affected.

Occupational therapists feel that it is important to address this issue from a preventative, health-promoting perspective. It is also important to help people cope with the symptoms or results of their condition and to prevent further problems. Investment should be provided so that preventative programmes that incorporate health-promotion and lifestyle-management strategies can be delivered to address the broad spectrum of issues among all clients across all age ranges.

A co-ordinated, all-systems approach to tackling the issue is necessary. There should be a national service framework for the treatment of obesity. Meaningful activities could be used as intervention. For example, people should be encouraged to become involved in activities that they enjoy, such as gardening or dancing, so that their mind and interests can be engaged. Ultimately, exercise on prescription should be broadened to include activity on prescription.

It is important that the home and general environment is accessible to people who are overweight or obese so that their problems are not compounded by being housebound, which can lead to further inactivity. Community integration should be encouraged to increase self-esteem. People will be motivated to maintain and improve their functional independence. That is particularly important for schoolchildren; it must be ensured that their schools, respite facilities and day-care facilities have the appropriate environmental design.

Occupational therapists endorse the concept of inclusive environmental design that considers the needs of all users, including those with obesity. We can provide expert opinion for that client group on equipment, environmental housing design, caregivers’ needs, lifestyle management and mental-health issues.

Overall, we recognise the challenges of our increasing obese population in Northern Ireland. However, we feel that further investment is essential across all our allied health professions so that equity for all can be delivered.

Ms Teresa Ross (Chartered Society of Physiotherapy):

I want to highlight the role that physiotherapy, along with the other allied health professions, plays in the management and prevention of obesity. The Clinical Resource Efficiency Support Team (CREST) guidelines point towards secondary care, but the management of obesity involves primary care and secondary care. It is a healthcare issue that concerns the whole population, not just one element of it.

Physiotherapists have the skills and expertise to assess and allow people to take part in exercise programmes and to undertake exercise prescription. Some of our work involves people with type 2 diabetes and people with musculoskeletal disorders, such as people with muscular sclerosis or neurological conditions that mean that they may be confined to a wheelchair. That means that one must look at other ways of allowing them to exercise, because they will not be able to go to a gym or take part in group exercise. Exercises must be modified to allow those people to have some kind of physical activity that will help to prevent secondary ill-health problems that can result from poor fitness levels. Such conditions include cardiovascular disease and stroke, and there are others.

From a physiotherapy point of view, exercise is important for a person’s well-being and self-esteem because the whole person is being treated. It is important to improve a person’s self-belief and self-esteem and allow them to have the confidence to take part in exercise. Exercise programmes have moved into leisure centres across the region. Those programmes are not just for people receiving primary care; they are for children and for those with an adult learning disability or a physical disability. People can go along and get introduced to exercise, take part, and then start doing those exercises themselves. However, some people are afraid to go into an environment where there are machines and equipment. The physiotherapist helps them to become accommodated safely into that environment, and our Over to You scheme allows people to take control of their own health and well-being. That is an important part of a physiotherapist’s role. Exercise is not something that physiotherapists can do to people; they must take control of it themselves.

Part of our job is to introduce patients to other environments. Obesity is a community issue and a population issue. It is not a health issue alone. It is a full-partnership issue; therefore, it is important to use all the partnerships that we can to help us to deal with obesity.

We must look at other ways of exercising. My colleagues mentioned dancing, walking, running, boccia and bowls. There are all kinds of exercises, and it is a matter of introducing people to them.

We take a person-centred approach. Although people may be referred with a sore back or a broken leg, ultimately, the whole person has to be managed. They may become inactive as a result of their condition, which may cause them to become overweight. That, in turn, may cause them to lose their self-esteem and their feelings of self-worth. It is important that behaviour be modified and that the person be built up in such care settings as successfully as possible.

Through the projects that we have run in primary and secondary prevention, we have found that the partnership that is involved is huge and that it must be developed. One cannot just treat the individual in question; everyone, including family, friends and neighbours must also become involved to allow for the peer support that people need to allow them to manage their problem.

Ms Gibbs mentioned manual handling. The Chartered Society of Physiotherapy leads a lot of the manual handling training for Health Service staff, including nurses, medics, allied health professionals and social workers. People are trained in how to manage obese patients safely, and that training then allows them to have the equipment and techniques in place.

Whenever obese patients are admitted to hospital, the theatres or X-ray departments may not be designed properly to deal with them. Physiotherapists advise on how to set up a department and manage the equipment and to have the necessary equipment in place or contracts available for bariatric patients to be well looked after.

The CREST guidelines of 2005 refer to the role of physiotherapy and the advice on exercise to enable people to manage obesity and to become fit. Of the people who present at physiotherapy departments, 20% do so for reasons other than being obese. However, that leaves us in a prime position to educate, train, advise and empower those people to look after their own lifestyles. Ultimately, a lot of the issue concerns a change in lifestyle and thinking.

A lot of schemes that have been run from a physiotherapy, allied health professional and multidisciplinary point of view have been funded by the Big Lottery Fund or by some other short-term grant. That has been a difficulty, because although the scheme may run for three years and be proven, it may then not get permanent funding. It is important that we influence that.

The incidence of falls is another factor that has an impact. I know that a lot of work is being done on falls, osteoporosis and other conditions. However, an obese person’s muscles become weaker — their muscle tone lessens and their balance reduces; therefore, the risk of falls or of osteoporosis from not doing weight-bearing exercises is increased. It is important that people’s lifestyles incorporate physical activity. That involves the entire community and every possible partner having an educational role.

Under the old arrangements, physical-activity forums considered the health and well-being of the population. They looked at deprivation and other issues and encouraged a multidisciplinary or multi-agency approach to the management of obesity. Allied health professionals are well placed to help and to influence that work in the future.

Ms Mulholland:

In summary, we hope that the examples that we provided help the Committee to recognise the significant contribution that allied health professions can make to the prevention and management of obesity. We look forward to working with many groups and agencies to deliver on that significant task. Again, we thank the Committee for giving us the opportunity to present our evidence.

The Deputy Chairperson:

Thank you very much Pauline, and thank you all for your contributions. The Committee recognises the key role that you play.

With the launch of the new Regional Agency for Public Health and Social Well-being yesterday, what do you consider to be the potential role that local commissioning groups (LCGs) and the agency itself can have in addressing health inequalities in general, but, in this case, obesity in particular? Obviously, that agency now has a key role in health prevention, promotion and education. Do you have any views on that?

Ms T Ross:

We welcome as really important the involvement of the new authority, the LCGs and the membership of the local government agencies in the new structure. As a chair of the local health and social care group (LHSCG) in the Southern Trust, I know that the relationship with local councils and other local partnerships was key to our being able to commission services that helped meet population needs — it allowed us to make decisions on the most focused investment that would achieve the best impact on a population.

Therefore, the new agencies provide a positive forum for us to build upon. Their involvement in local communities will be a good influence, and the involvement of local council representatives will help to build a better future.

The Deputy Chairperson:

There will be an increase in leisure opportunities, which comes back to that multi-agency approach.

Ms Mulholland:

The point is to combine the best examples of what has worked across the region and to roll them out in the mainstream. At the same time, we must consider what has been tried and tested and what fits with a particular local community, because all communities are different. It is about what the people in those communities and voluntary groups think will work and what they are happy to engage with so that the desired outcomes can be achieved.

Ms T Ross:

The other point to make about leisure opportunities is that it is really important that the rules, and an open approach, are standardised. Some of our examples show that a partnership with the providers of leisure facilities on issues of costs and other matters can be built more easily in some places than in others. A common approach would be good, because it would to allow for healthy activities to move into other arenas.

Mr Gardiner:

Tracey, as a representative of occupational therapists, how do you deal with obese people who have a mental illness or a learning difficulty?

Ms Gibbs:

That is certainly a challenge for those therapists who work in front line services. For example, patients with mental-health difficulties have usually been attending occupational-therapy services for a number of years, and it is important to engage them in a specific, tailored and therapeutic activity programme to gradually reintegrate them into the community. That is done by identifying their hobbies and interests, trying to regenerate their ability to become involved in leisure activities and, ultimately, participation in the recently established condition-management programmes, through which occupational therapists try to enable people to get back into work through vocational rehabilitation.

Therefore, we deal with such patients through a range of programmes that involve both individual and group work. Occupational therapists have been working with folk who have mental-health disorders and have been trying to overcome the issue of obesity and the problems that it causes.

In addition, from a learning-disability viewpoint, an increasing problem for occupational therapists is the use of equipment, and wheelchair sizes in particular reflect that. Our population is possibly getting more overweight — obese — which results in challenges in sourcing the most suitable wheelchair for a patient to ensure that it fits into his or her day-care centre, respite facility and home environment. Along with our physiotherapy and dietetic colleagues, we try to address the huge implications of obesity and to ensure that the home life, work life or school life of a patient is as manageable and independent as possible. That is achieved through individually tailored activity-based programmes, correct supply and prescription of equipment, close monitoring of a patient at home, and very close liaison with teachers, care givers and the whole carers’ network.

Mr Gardiner:

What percentage of the patients that you treat have a mental illness or a learning difficulty?

Ms Gibbs:

I work in an acute hospital and deal with physical disabilities, so I cannot give you the exact percentage offhand. However, I can source that information for you.

Ms Mulholland:

Allied health professionals know that occupational therapy is the most recognised therapy for mental-health and adult disability. Therefore, a much higher proportion of occupational therapists work with clients who have mental-health problems.

The Deputy Chairperson:

Can I clarify whether allied health professionals are represented on the obesity steering group?

Ms Mulholland:

No, they are not. One of our recommendations is that allied health professionals should contribute to that group’s work. We are involved, but not directly; one of our colleagues managed to be nominated by her trust to one of the subcommittees and has introduced the idea that it is important to have dieticians represented on the group. We have managed to get a dietician on the food and nutrition subgroup; the British Dietetic Association was not invited to sit on the food and nutrition subgroup, even though such matters are our core business and we are the only professionals in the healthcare system who are regulated to act on those issues. We have a role to play on the obesity prevention steering group.

The Deputy Chairperson:

I think that Committee members would agree with that point; I certainly do. As I said at the start of the meeting, you have a key role to play. That might feed into our recommendations.

Ms Mulholland:

I plan to send a letter to the chairperson of the subgroup asking whether they would like us to contribute.

Dr Deeny:

Ladies, I thank you for appearing before the Committee. As a doctor, I think that it is vital that you should be a representative of allied health professionals on the steering group. I should know this, but could you remind me of whether there will be two allied health professionals on each local commissioning group?

Ms Mulholland:

As far as I know, there will be only one representative for a minimal amount of time — approximately one or two days a month.

Dr Deeny:

I want to focus on the prevention of illness through exercise. Everybody is talking about that, and it is a multi-agency, cross-departmental issue. As a community physician and a GP, I want the education sector to be involved, and I am glad that councils are involved. Tracey mentioned environmental design. As an OT, what practical measures do you think could be taken to help facilitate people’s exercising in their own homes? How can we facilitate that environmental design in order to tackle the epidemic of obesity?

Last week, the Committee Clerk gave me a document that shows that GPs in the Belfast Health and Social Care Trust can prescribe leisure centre activity to patients. Although there was an arrangement in the west at one stage, GPs in the Western Board and other areas cannot prescribe in that way, and we must address that matter. Rather than wait until people get sick, if we are serious about real health promotion and disease prevention in the future, it is important that we establish a facility whereby GPs can use methods other than prescribing drugs in order to help people to lose weight.

As a GP, I want to be able to access patients whom I consider to be morbidly obese and whose health is threatened. Why should I be unable to prescribe physical activity as opposed to drugs, which are much more expensive? That is how we should progress. I was shocked by the document that the Committee Clerk gave me last week. I was pleasantly surprised to find that GPs in some parts of Northern Ireland refer patients to leisure centres. However, that does not happen in other parts.

Ms T Ross:

I know that GPs in the Southern Trust prescribe exercise. They refer patients directly to leisure centres. Thereafter, the fitness instructor and the physiotherapist in a leisure centre work in partnership to assess the patient and set up an individual programme for them. The fitness instructor then takes control of the exercise programme. However, the fitness instructors require some training.

That would definitely be a positive way to progress and would allow the health system to target people who are at risk of ill health, as opposed to those who are actually ill. Therefore, it is important to develop the idea of prescribing exercise, and it should be rolled out.

Dr Deeny:

The Committee Clerk has just handed me a document about the pre-fitness GP referral scheme. It is 12-week scheme that is similar to other UK schemes, and it operates in conjunction with the Eastern Health and Social Services Board’s Healthwise scheme. It is co-ordinated by the GP referral officer at a fitness centre. I think that such schemes are part of the future of healthcare and the prevention of illness.

Pauline is correct: such schemes will identify people who are perhaps a year or two away from a major health event or illness. Diabetes is already visible in young people in primary care. It used to be called maturity onset diabetes, but it can occur at any age, so it is now known as type 2 diabetes. Given that, such schemes must be a major part of our health strategy for the future, and we need to push access to them. We perhaps need to reach a point at which nurses can prescribe exercise, after having consulted with GPs and identified those patients that should be referred to leisure centres.

Ms Mulholland:

That is one opportunity that the new Regional Agency for Public Health and Social Well-being will create. For example, how do we find out what is going on in different parts of the Province? Many schemes have been introduced in patches, and the Healthwise scheme in the Eastern Board area — where I am from — has been running for some time. I think that it was, perhaps, established on the back of Big Lottery funding. Several health-prevention schemes have received Big Lottery funding, but they did not receive the mainstream funding that would have enabled their benefits to be rolled out.

The Cook It! programmes, which promote healthy cooking, are one example of an environmental scheme. They are funded by the Big Lottery Fund across the Province and have received mainstream funding in two trust areas. However, in others trust areas, they have not received such funding. Therefore, some of our population has access to absolutely fabulous programmes that work and that have been evaluated, but those programmes do not exist in other areas. That inequity must be addressed, and the introduction of our new structures and way of doing business will provide an opportunity of which we must take advantage.

Ms Gibbs:

With respect to environmental issues, our colleague Padraig O’Brien is working with the Housing Executive. However, occupational therapy needs more resources and more specialist knowledge of housing issues. In Northern Ireland, there is just one occupational therapist who is a clinical specialist in housing. Presently, he happens to work in the Northern Trust.

With such a person in place, specific research can be carried out in, for example, evidence-based practice, enabling us to prove which equipment is the most effective and efficient by trying out various devices in peoples’ homes. In different trusts, various waiting lists exist, and an assortment of equipment is being issued. Therefore, the range of equipment that is fit for purpose, research based and most efficiently costed must be streamlined.

Another way to move forward would be to have dedicated occupational therapists working specifically in housing. Other essential groups with which we must work and have closer links include housing authorities, the Housing Executive, the private sector, local schools and special schools. In addition, we must consider the whole area of risk management and become more environmentally efficient by devising practice standards in communities that ensure that any equipment that is to be recommended and prescribed is the best that we can deliver.

Dr Deeny:

My question could apply equally to physiotherapists. There are not enough occupational therapists, who play a vital role in health and community care. Will you provide the Committee with statistics outlining how many OTs are in each of the five trust areas?

Ms Gibbs:

Yes.

Dr Deeny:

Could you also provide the Committee with the college’s estimate of how many OTs each trust should have? Most of us would agree that —

Ms Gibbs:

There are 770 qualified professional occupational therapists in Northern Ireland, and the College of Occupational Therapists has 27,000 to 28,000 members. There are probably more than 200 occupational therapists in the Belfast Trust, approximately 120 in the Western Trust, and the remainder are dispersed among the other trusts. However, I can submit precise and up-to-date figures.

Dr Deeny:

I would appreciate that. How many OTs does the college suggest that there should be in Northern Ireland?

Ms Gibbs:

We have just submitted a response to workforce planning in the College of Occupational Therapists. The recommended numbers for each person in the population is much higher than the present numbers, but I can get the specific figures from our policy officer for Northern Ireland and forward them to you.

Mr Gallagher:

I am glad to hear that there are so many OTs in the west of the Province; however, there appear to be few in places such as Fermanagh. That is an ongoing problem, but it is not for you to deal with today. Nevertheless, it will be interesting to see the figures when they come through.

You talked about the important role that dieticians must play. In addition, the British Dietetic Association mentions both the importance of having highly trained professionals and the need for support — including financial support — for them. Given that we must pay more attention to the problem of obesity, can you give us some idea of the position with respect to the population of Northern Ireland? Do you feel that we have enough well-trained professionals to work in that sphere?

Ms Mulholland:

All the areas of work in which we are involved are regulated professions, and we are all regulated by the Health Professions Council.

Mr Gallagher:

Does that include experts in diet?

Ms Mulholland:

Yes, dieticians are regulated by the Health Professions Council. We are all graduates who have had to go through a training programme. We face challenges, in that others who are not regulated and trained in that way provide dietary messages that are not consistent with evidence-based practice. Being called a dietician is a protected title for all those who work in that area. Therefore, if you call yourself a dietician, you have to be regulated by Health Professions Council.

We recognise that there are limits to the number of dieticians in the Province. We are in a difficult position in healthcare, and we are all aware of the budgets. We recognise that we need more dieticians. We are working with the Department of Health’s service delivery unit to look at new access criteria with regard to waiting-list management. One criterion that we have set is that we would accept referrals from any health professional for a patient who has a body mass index that is greater than 30, which is clinically obese. The capacity is not there for us to deliver on that, so that is a challenge, and we would like to raise that issue with health commissioners and have that criterion accepted.

However, we have to be honest and say that dieticians are not the only ones who work in that way; our nursing and medical colleagues, GPs and practice nurses are all key and have their own messages to give. As a profession, we also work with commercial slimming companies. With regard to Dr Deeny’s point about exercise on prescription, there are examples in England of people’s being given access to weight loss on prescription. There needs to be a way to validate and ensure that commercial companies are reputable and that they follow evidence-based work.

To answer the question, we would honestly have to say that we do not have enough dieticians. We would want to have more highly specialised dieticians to look at prevention strategies. We can lead on those strategies and work with others to deliver them, because our expertise is in setting up the mechanisms. We work with community groups to deliver those strategies, and we do so very much on the clinical specialist side

One of our big challenges is that the majority of people who come to dieticians with clinical problems of obesity come with other medical conditions that need to be considered, such as diabetes and heart disease. The issue is not necessarily about just healthy eating; other dietary complications need to be managed.

The Deputy Chairperson:

Your paper refers to the role of a consultant dietician and support workers.

Ms Mulholland:

There are a number of consultant dieticians working on obesity in England. That is a new role, and those consultants are highly specialised. They exist for all the allied health professions. It is a growing area. However, we do not have any consultant dieticians leading on obesity in Northern Ireland. Their roles are split 50/50 between research and practice, and they are very much looking at undertaking research in the population and providing advice on strategy, development and clinical practice for all dieticians — potentially across the Province, if such a post existed.

On the other side of the scale — which fits in with the recommendations in the priorities for action to look at the distribution of unqualified healthcare workers to qualified colleagues — we have dietetic assistants, and the other professions have comparable assistants.

That is a new and growing role in dietetics in Northern Ireland, and the key things that dietetic assistants can do for we dieticians is to translate the messages that we give to patients into real-life actions for them and to support them to understand those messages. For example, we have looked at providing dietary advice on obesity to individuals or groups. A dietetic assistant could then take a group of patients to a supermarket and show them how to read labels, which they might have done in practice. They can take a product off the shelf — for example, margarines and spreads — and point out the differences between them.

Therefore, the point is to translate the message into practice, because so many messages are very confusing. When you go to the supermarket, you need to know which is the low-fat product and which has sugar and which does not. Are low-sugar biscuits OK? No, they are not, because the sugar has been taken out and fat has been added, making them worse than the standard product. That is the role of the dietetic assistant — they take those messages, translate them and make them live for individuals.

Mr Buchanan:

Thank you for appearing before the Committee today. No doubt, if we want to tackle obesity, a multi-agency approach has to be taken in order to take it on and do something about it.

Throughout your presentation, you talked about the issues that are key to tackling obesity. Exercise and education are crucial, as are education and peer support for people who participate in some of those activities. How do you encourage people to participate in exercise, leisure, or in the programmes that you talked about that are being put in place? How do you encourage people who are in the obese category to participate in exercise to seek to reduce their weight and to make themselves healthier?

What work do you do with young people in schools or colleges to seek to get the message across that obesity is a serious problem and is something that everyone has to consider? How do you measure the results? I am sure that in your profession you deal regularly with many obese people. How do you measure the results of the programmes that you have in place to ensure that they are having an effect on the people with whom you are dealing?

Ms T Ross:

From a physiotherapy point of view, we work across all the programmes of care, which means that we work with adults with learning disabilities, with children, with people who have physical disabilities, and with people in primary-care settings. Therefore, in all those fields, there is an opportunity to influence those people to take part in exercise.

For some people, it is about looking at what they can do in their own environment. A lot of it is to do with motivation, with trying to get people to change their mindsets and getting them interested in exercise, as well as trying to talk to them to find out what they like to do. We can prescribe exercise, but unless it links to people’s lifestyles, their family environments, or getting support from their families, they may not continue with it.

In mainstream schools, we have a programme for obese children, and the biggest success was when the parents, children and their siblings came to the programme together, took part in exercise and got advice on diet and exercise. It was a learning curve, and at the end of the 12 weeks — and even when we reviewed it a year later — they were sustaining the programme because they were supporting one another.

The change in the individual family’s self-esteem and confidence has been really evident with some of the schemes that we have run for adults with learning disabilities. There are issues around obesity and being overweight and accessing leisure and community groups and sporting teams. However, through physical-activity forums, we work in partnership with education providers, local football clubs, hockey clubs, and so on. Therefore, we are taking a community-based approach to the issue.

We assess people’s ability to take part in exercise or fitness regimes. We assess the risks that are involved and devise a programme that fits in with those and with their lifestyle. Therefore, it is important to know what someone is interested in and to find out where they can avail themselves of that activity. We can widen the whole partnership to include community development, local councils, and sports organisations. The impact that it has is very good.

We can weigh people, test their blood pressure and cholesterol and monitor all those things, but the greatest effect is on people’s confidence, well-being and self-esteem. If people go for a walk, join a walking club, go dancing, or even go out, their whole body image improves greatly and they feel so good that their ability to meet other people and to converse with them also improves. Therefore, such programmes have very beneficial effects on quality of life. People get all the health benefits from having their blood pressure, cholesterol and similar physical elements tested, but they also get improved quality of life and well-being, and their mental health improves. Therefore, the whole family unit and community benefit.

Ms Mulholland:

There has been a huge campaign to improve nutrition in schools. Standards for the provision of food in schools have been set that have been implemented. One of the most recent developments has been the employment of a dietician in the Health Promotion Agency as a schools’ co-ordinator. Under the aegis of the new regional health agency, she will have a key role across the Province in evaluating how nutritional standards are implemented in schools. Nutrition advisers assess those standards regularly in schools to determine how they are progressing against their targeted tasks. They also give feedback and provide timescales for progress.

Ms Gibbs:

When it come to measuring the effectiveness of our service, I should point out that occupational therapists cannot always pick up on patients in a physical setting until they present to an acute medical ward with, perhaps, a diabetes-related, arthritic or chest disorder. Those people come in with chronic conditions, and although they happen to be obese, we are unable to intervene — or to know anything about that client group — unless they are given a bed in a medical ward. Very often, we are dealing with compensation and addressing secondary problems. In future, hopefully, with more representation at departmental level and with more strategic guidance, we can employ ways to intervene at an earlier stage and work collaboratively to address the problem upstream rather than downstream, which lessens the effect of intervention.

The Deputy Chairperson:

That concludes our question-and-answer session. Thank you for your presentation and your submissions to the Committee; they have been very helpful to our inquiry.