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Official Report (Hansard)

Session: 2008/2009

Date: 05 March 2009


Inquiry into Obesity - 
Department of Health, Social Services and Public Safety

5 March 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 
Mrs Carmel Hanna 
Mrs Claire McGill 
Ms Sue Ramsey

Dr Naresh Chada ) 
Mr Andrew Elliott ) Department of Health, Social Services and Public Safety 
Mr David Galloway ) 
Mr Rob Phipps )

The Deputy Chairperson (Mrs O’Neill):

I welcome Andrew Elliott, the director of population health, Dr Naresh Chada, a senior medical officer, Rob Phipps from the health development branch, and David Galloway, the acting director of secondary care. I invite the witnesses to make a short presentation, which will be followed by questions.

Mr Andrew Elliott (Department of Health, Social Services and Public Safety):

Thank you for inviting us here today and for helping me to skip introducing my colleagues. My responsibilities include improving and protecting the health of the population — in other words, the public health policy remit, reporting to the Chief Medical Officer — and I am accompanied by David Galloway, who will pick up on matters of concern to the Committee, concerning the treatment of obese people.

The Department of Health, Social Services and Public Safety welcomes the Committee’s interest in this important health issue for our times and for the future. As members are probably aware, this matter has been described as a time bomb, which will have a significant impact on the health and, indeed, wealth of all our futures. We live — at least in this part of the world — in a time of abundant food, but our ancient physiology is based on famine. Consequently, our bodies are designed to seek out, and consume at every possible opportunity, salt and — more pertinently for the purposes of this discussion — sugar. Therefore, it is no surprise that the food industry has recognised that fact. In a time of plenty, it is well placed to offer us whatever our genes have told us to desire. Furthermore, in recent decades, there has been a significant change towards more sedentary lifestyles, and there is a real issue with changes to our built environment not only in Northern Ireland but elsewhere.

No doubt Committee members have had an opportunity to read the Department’s written submission, and I do not propose to repeat it. Instead, I shall mention some of the key issues.

It is important to articulate that tackling obesity is one of the most important public health issues with which the Department is dealing. The ‘Northern Ireland Health and Social Wellbeing Survey 2005/06’ indicates that 59% of adults surveyed were either overweight or obese. The figures for children were lower, but they are still extremely worrying and are on the rise: 5% of five-year-olds are already obese, and 22% are overweight. The fact that the trend is rising gives enormous cause for concern, although the most recent figures indicate a little easement. We can return to that point.

It is important to note that the figures that I have quoted are similar to those found in Europe and North America, so we are all facing a similar problem. Therefore, a component part of the Department’s work will be to monitor interventions elsewhere closely, particularly if they are found to be effective.

The twin problems of too much energy in and not enough energy out — in other words, the lack of a healthy diet and an inadequate amount of physical activity — have long been recognised as risk factors for coronary heart disease. That fact was recognised here in the late 1980s, and those factors became the two essential targets in the Change of Heart programme, which some members may remember.

Throughout the 1990s and the early part of this decade, resources were directed towards promoting healthy eating and increasing physical activity, and those measures continue to form part of the Department’s work. In 2002, the Department launched its acclaimed Investing for Health public health strategy, which was important because it picked up on many factors relating to health determinants and wider issues.

At that time, there was a key change in strategic thinking, resulting in the Department identifying the need to focus on childhood obesity. It is not just an issue for the Department of Health, Social Services and Public Safety but one for cross-Government action, which is why the Fit Futures task force emerged in order to put in place an action plan aimed at preventing children and young people being overweight or obese. It contained recommendations for integrated cross-departmental action. That was made manifest by the development of a joint target among the Department of Health, Social Services and Public Safety, the Department of Education and the Department of Culture, Arts and Leisure to halt the rise in obesity in children by 2010. The final report of the Fit Futures task force was published in 2006, which identified a number of priority approaches: over 70 recommendations for action were made.

The Department’s current position on prevention is to build on Fit Futures, but to move to a position founded on recognition of the importance of addressing obesity across the entire life course. The vast bulk of our present work on obesity is founded on that principle of aiming at the whole life cycle. We remain committed to a cross-departmental and cross-sectoral approach. We recognise that, as well as the Department of Education and the Department of Culture, Arts and Leisure, other Departments also have a vital role to play. We will continue to press for a greater use of health impact assessments by Departments with responsibility for the built environment and for regulation of the food industry.

Our written evidence shows that we committed to developing an obesity prevention strategic framework by spring 2010. In the meantime, actions and initiatives that address childhood obesity in support of Fit Futures will continue. The new framework will not be a panacea. Challenges remain, particularly those related to what is known as the obesogenic environment, an environment in which it is more difficult for people not to become overweight. We are trying to tackle a long-term lifestyle issue in a world where the emphasis is often placed on short-termism. Our obesity prevention strategic framework must address those kinds of challenges and turn that trend around. That will not be easy, and it will not be possible for my Department to achieve that on its own.

I hope that we will have a chance to pick up on those issues in more detail during questions. I ask Dr Chada to make a few introductory remarks about the health and wealth impacts of obesity.

Dr Naresh Chada (Department of Health, Social Services and Public Safety):       

Thank you very much for outlining the key issues, Andrew. I speak as a doctor and a public health specialist; I am extremely concerned about obesity, as are other colleagues in the Department of Health, Social Services and Public Safety, particularly the Chief Medical Officer.

I will give the Committee a quick overview of some of the health impacts associated with obesity. We are all aware that heart disease and strokes continue to be among the biggest killers in Northern Ireland, and smoking causes much of that. However, obesity is an important risk factor for those conditions. If someone is under the age of 50 and happens to be obese, he or she is twice as likely to suffer a heart attack or have a stroke.

We are all aware of the many people in Northern Ireland who have diabetes: 65,000 to 70,000 people suffer type 2 diabetes. If one happens to be obese, one is 20 times more likely to suffer from that condition. The Institute of Public Health in Ireland has done much detailed modelling, particularly with respect to the way in which type 2 diabetes is likely to increase over the next five to 10 years. If we do not halt the year-on-year increase in obesity, we could have another 10,000 to 15,000 people with diabetes in Northern Ireland by the early to middle part of the next decade. That is also a matter of particular concern.

Other health issues are not as intuitively obvious. Cancer — particularly gynaecological cancers — are also associated with obesity. I refer to cancer of the uterus, cervix and ovary. Men may be affected by bowel and prostate cancer. A certain proportion of cancers can be attributed to obesity. Conditions of the respiratory system are also associated with obesity, including sleep apnoea and associated breathing problems.

We are all aware of the problems that orthopaedic conditions cause, both with regard to pressures on the Health Service and the wider workforce. Lower back pain, hip and knee issues are also associated with being overweight and obese.

That is a range of the issues that are associated with obesity and the public health impact that are important to everyone. I am sure that the Committee will consider those as serious issues.

I want to talk about health economics issues. Health economics is an inexact science, but I will quote some facts and figures associated with the costs of obesity. The 2003-04 House of Commons Select Committee on Health Third Report estimated that the cost of obesity was £3·7 billion per annum, which is a considerable resource.

The ‘Foresight: Tackling Obesities: Future Choices’ project report — to which we will refer throughout the evidence session and which forms a large part of the evidence base and policy behind current thinking on obesity — suggests that, by 2050, at current prices, we will be spending £10 billion a year across the country on direct Health Service costs associated with obesity. There will also be costs of around £50 billion a year associated with the loss of productivity and workforce issues. Huge resources are involved if we do not tackle the issue of obesity.

There are other estimates relating to Northern Ireland. It has been estimated that 260,000 working days are lost each year because of obesity-related conditions, costing the economy approximately £500 million. A recent Northern Ireland Audit Office report, ‘Obesity and Type 2 Diabetes in Northern Ireland’, states that, throughout the UK, diabetes is thought to cost the Health Service around £1 million an hour. In Northern Ireland, that translates into around £1 million a day. Type 2 diabetes is closely related to obesity and has a huge economic impact.

Mr David Galloway (Department of Health, Social Services and Public Safety):

Generally, people present in the health system through morbidities other than their weight. That is recognised in the general medical services contract through the use of quality and outcomes framework (QOF) points and directed enhanced services (DES) for long-term conditions management. Some £800,000 has gone into supporting those DES directions, and 90% of GP practices have signed up to them. We have very high rates of achievement in the DES points, and high scores against QOF points.

Currently, we do not have any clear data to show the difference that primary care activity has made for those people. When they come into the secondary care system — Naresh has already outlined the impact of obesity on the health of those individuals — there is a significant knock-on effect for the secondary care sector.

There are services that are more specifically directed toward treating obesity and overweight people. We can refer people to a dietetic service, which can examine their diets. People who present for surgery will undertake preoperative assessments that offer them advice about managing their body weight, lifestyle, nutrition, exercise, and so on.

At the far end of that spectrum of activity is the possibility of surgery for those who are extremely obese. In the past, the National Institute for Health and Clinical Excellence (NICE) has issued guidance on access to bariatric surgery, and the Department has endorsed a clinical guideline for Northern Ireland. As such, it remains an aspirational programme.

Bariatric surgery is not currently commissioned by the health boards in Northern Ireland, although, last year, £1·5 million was made available to ensure that some 120 people had access to bariatric surgery from providers in Great Britain. The boards are currently discussing how they might progress that issue in 2009-2010 to ensure that that service is provided to the people who are most likely to benefit from it.

The Deputy Chairperson:

Obesity is a cross-departmental issue, although the Department of Health, Social Services and Public Safety will carry the brunt of the cost of providing treatment and helping people. The steering group has been going for almost a year. Is there a good level of engagement by the other Departments that are represented on the steering group?

Mr Rob Phipps (Department of Health, Social Services and Public Safety):

The short answer is yes. We mentioned the public service agreement (PSA) target for childhood obesity in our written submission. It is shared among the Department of Health, Social Services and Public Safety, the Department of Education and the Department of Culture, Arts and Leisure. There has been a strong partnership since 2004, but the steering group has invited other Departments to become involved. When we start to develop the framework, we will go back to those Departments to ask for outcomes; it is not enough simply to attend the meetings. I assume and expect that further discussions will take place.

The Deputy Chairperson:

As you develop your framework, this inquiry will feed into it.

Mr Phipps:

The timing is brilliant.

The Deputy Chairperson:

It has worked out well.

Dr Deeny:

I also have an interest in this subject. I see that three Departments are involved.

We all know about diet and exercise. There is a strong focus on diet, which is as it should be. However, there is a lot of talk about exercise but, perhaps, not enough action. Families and schools are important. I said last week that I believe that some schools have placed too much importance on academic achievement as opposed to exercise. Those of us who are privileged and lucky enough to have children have a responsibility to see that they get good exercise. I have two sons who are heavily involved in sport, but I have a daughter who is not getting enough exercise. In this electronic age in which there are so many interesting things to do on a computer, for example, I wonder what we should do as a Committee.

Should it not be mandatory for schools to provide at least two to three hours of exercise a week for our young people? I have seen what is happening in general practice. I have been a GP for many years, and I am now seeing young girls who tell me that they are smoking. When I ask them why — because we have to record information about their smoking — they tell me that it curbs their appetite. That is a worrying development, not to mention the fact that they are not getting enough exercise. We are too focused on what young people should not eat, but they are doing something that is harmful to their health in order to curb their appetite. We should focus on getting young people to take more exercise. Is the Department of Education thinking along those lines? I think that it should be. Should we be saying that the Department of Education should play a role and act quickly? It is just not good enough that schools concentrate on getting top marks at the expense of ensuring that young people get enough exercise.

Mr A Elliott:

The support of the Committee on issues such as this is important. Each Department has its own challenges to face and has a lot to deal with. It is also important to say that, when it comes to the capability to learn, the mental health and well-being of children are paramount, and sport and activity can contribute to that. There is a double benefit in tackling obesity in that it helps to improve mental health and well-being.

Mr Phipps:

Will you invite the Department of Education to this Committee?

The Deputy Chairperson:

We have not decided that yet.

Mr Phipps:

Physical education is a compulsory part of the curriculum for children in years 1 to 12.

It is up to each school, but Department of Education guidance states that they should do at least two hours’ exercise a week. In 2007, the Minister of Education launched the Curriculum Sports programme for primary schools, which aims to develop physical literacy skills. Therefore, schools are putting an emphasis on physical activity.

There is also the Health Promoting Schools programme, which addresses all areas. Therefore, although there is an emphasis on food and healthy eating, there is also an emphasis on physical activity. There are local activities and initiatives that involve young people of school age in physical activities, which are possible because of the Fit Futures funding that we provide to the health boards.

You may wish to ask the Department of Education about its guidance, but our view is that it recognises the importance of physical activity.

Dr Deeny:

Is guidance good enough? Certain schools do not seem to be following the guidance. Is there no way to pull those schools up on that?

Mr Gallagher:

The Department of Education will say one thing on guidance but then say that there must be 27 curriculum choices delivered at post-primary level. The Department is defeating its own guidance on exercise, because PE, games and sport are squeezed because of pressure from the other curriculum choices. Therefore, there is a bit of a problem.

Mr A Elliott:

Schools will only ever be one component in tackling obesity — it will never be enough to rely on schools to solve the problem on their own. I can remember a piece of correspondence that our Minister received in which a doctor wrote that there was a school on the outskirts of a Fermanagh village that had no pavement for, perhaps, 100 yards from the school gate. If the authorities had designed the pavement in a different way, many more children could have been walking to school instead of being driven, because their parents were worried about them being knocked down.

There are many issues about how the Government and their agencies think about health and creating opportunities for movement and activity, even short of the formal sports curriculum. It is important for politicians, Ministers and Departments to begin to tackle and wrestle with those issues if we are to succeed in reducing the obesity problem.

The Deputy Chairperson:

We must work together rather than in silos.

Mr Gardiner:

Prevention is better than cure. Rather than nine of us on the Committee for Health, Social Services and Public Safety sitting around and listening, we must put our hand to the plough and see the work through. Along with the Departments, I hope that we can launch a publicity campaign by engaging with the ‘Belfast Telegraph’ and booking a page in all the local papers and the better-selling papers to get the message across.

Mr Buchanan:

That will cost.

Mr Gardiner:

It will cost more to treat a patient than to advertise to the public what they can do to prevent some of the illnesses associated with obesity. That can even be done at school level. We must work on getting that message to the public — we will not be able to get the message out as things stand, and people will continue to die. We must get the message across, come hell or high water.

The Deputy Chairperson:

Are you talking about a Committee initiative?

Mr Gardiner:

The Committee can push the initiative and push the Department to act. There could be a joint effort. I do not care who is involved, as long as we get the message to the public.

The Deputy Chairperson:

We can explore that further.

Mr Phipps:

Some of the funding that we have given to the Health Promotion Agency has been to promote physical activity through campaigns.

Mr Buchanan:

It is not working.

Mr Phipps:

As Andrew said, one of the key issues and difficulties is sustainability. The same applies to climate change — you have to keep going.

One of the difficulties that we have had in the past, because of the nature of the funding, is that one cannot get that degree of sustainability. I totally agree that we need to engage the population. It is a kind of social marketing. A number of countries are developing a social-marketing approach, which includes campaign work and getting the support of environmentalists. If there is to be a physical activity campaign, it is essential that the infrastructure is in place.

Schools were mentioned. Everyone should be on board, otherwise the campaign will sit by itself. The Foresight report states that there cannot be a series of one-offs; it must all be brought together. A campaign is absolutely right, but it must form part of the whole picture, and it must bring other Departments on board and get them involved. We must get the other bits together.

Mr Gardiner:

We must start to get it right. There is not much point in sitting here talking about it. We want action.

Mr Phipps:

I agree totally; we need action, and we also need other people on board.

Mr A Elliott:

There is also a health inequality dimension, which is important to articulate. If a child happens to be lucky enough to be in a wealthier household, that child’s parents may drive him or her around from one interesting activity to the next on many evenings each week. If a child comes from a home without that luxury, he or she may be considerably disadvantaged as regards the risk of obesity. Therefore, we must see what we can do. For example, there is a beautiful natural environment around Belfast, but how accessible is it, how much is it used, and how safe do people feel when they use it? There is a whole host of issues that must be played into this discussion to get people moving and to get them out into the natural environment. I am thinking of Black Mountain, for example.

Mr Buchanan:

No doubt, this is a huge concern right across Northern Ireland, when one considers the amount of working days that are lost and what that costs the economy and the Health Service. It is a big issue that must be tackled.

I was going to ask a question about education programmes, but that has already been answered. Schools used to buy into them. Programmes are in place in schools, and perhaps they could be widened in order to make sport or some such activity more creative for the children. Some children do not like sport as much as others. We must open it up and make it more creative to get them involved in some other type of physical activity. However, it goes wider than that.

What initiatives are available at GP surgeries or in local health centres, so that patients who attend those centres are made aware that there is an obesity problem that must be dealt with? Those patients need to take on the responsibility to deal with their situation. District councils provide parks and leisure facilities. However, we must get the message across to people to use those facilities, which will help them to tackle their obesity problems.

There is another element. Some people are on the edge of obesity, and they do not realise it. They may be slightly overweight and think that their condition is not too bad. It does not register with them that they are in that situation — perhaps I am there myself. However, we need to consider that issue.

I listened to Sam’s suggestion, but the Committee do not have the finances available to do that campaign. However, the new public health agency has been set up specifically to deal with such issues. Perhaps the Committee should write to the agency and ask it what strategies it has in place and how it proposes to tackle the issue of obesity.

Members are well aware of the DUP stance on the public health agency. There is no point in setting up such a body only to find out that the Committee has to pick up on something that the agency was established to deal with. As a Committee, we have to hold that body to account and examine exactly what it is doing.

Another challenge is the modern world of technology. Everybody is sitting pressing buttons rather than being active. We must tackle that issue in order to overcome obesity.

Is obesity more prevalent in socially deprived areas?

The Deputy Chairperson:

We received a submission from the current public health body, the Health Promotion Agency. When the new public health agency is formed on 1 April 2009, we intend to invite its representatives to a meeting to put that question to them. That will probably be after the Easter recess.

Mr Galloway:

I will start by explaining the primary care end of things. Primary care has a vital role to play in communicating the right messages about obesity and how people could try to manage their own weight, diet and level of physical exercise. Material is available to assist general practices to do that. In my introductory remarks, I said that that has been recognised in the formal structures for the general medical services contract.

Other options are available. In some parts of Northern Ireland, GPs are able to refer people to physical activity programmes that are run in conjunction with local authorities. That is not universally available across the Province, but that is the sort of activity-driven solution that GPs can offer when they believe that the issue is about encouraging someone to take part in physical activity. Those are the major elements with which GPs will deal without going into other forms of treatments, such as drug therapies, to curb diet or deal with weight gain.

Mr Phipps:

There is a gradient of social class. A smaller proportion of social class A or 1 is overweight or obese than social classes D, E or 5. There is a whole range of issues around inequalities and access, which is very difficult to untie. The facts are there, but people give various reasons to explain them. There are certainly issues around access to fresh food and the kind of pressures that people may or may not be under. It is a very complex issue.

Dr Chada:

I reinforce Rob’s comments. For most diseases and illnesses, there is usually some sort of social class gradient, which is prevalent and ubiquitous in public health. As Rob said, it appears that that is the case for obesity. There is probably a great deal of regional variation, both at a micro level and nationally. Again, one could try to unpick what the reasons for that may be, but it is likely to be a number of factors.

Mr Phipps:

One of our responses to the board is to ensure that any initiatives are targeted at health inequalities so that localised targeting also occurs. There is a range of initiatives.

Ms S Ramsey:

I think that I will be a fly in the ointment today. Before I do that, I declare an interest as somebody who is overweight.

You said that your Department, the Department of Culture, Arts and Leisure and the Department of Education have a shared commitment to tackling obesity, and thank you for providing the Committee with a good paper on the various steering groups and working groups. However, it strikes me is that, having seen some good advertising campaigns on television, there needs to be an overarching publicity angle. That follows on from earlier points: Samuel was right about the need for publicity and, as Thomas said, district councils also have a responsibility to publicise their leisure facilities. My district council, of which I was a member for several years, provides 26 play parks, but only one of them is in a nationalist area. We must consider the cost of entry to leisure facilities. You made a point about what is happening in Belfast, but there are other issues.

My concern is about overall responsibility: can the Department of Health, Social Services and Public Safety simply take the lead on tackling obesity? Departments are arguing about which of them should fund schemes such as Sure Start or after-school projects. Who intervenes to say that enough is enough and tell an individual Department that it must fund a particular project or scheme? Representatives from areas of social disadvantage are fighting with the Department for Social Development about neighbourhood renewal. Who intervenes to demand that it be funded? An overarching strategy exists to deal with obesity and associated illnesses. However, if one Department says, for example, that it will not fund Sure Start or an after-school project, or if a council refuses to set up particular play facilities, who intervenes to insist that the funding goes ahead? Each Department is fighting for its budget.

It takes me back to the Investing for Health strategy. It was a key document at the time and all Ministers signed up to it. We now need to put Ministers and the Executive behind the eight ball and tell them that it is one thing to agree to the strategy, but they must be aware of what is happening on the ground.

The other day, the Assembly debated the advertising of cigarettes. Where do the supermarkets and manufacturers sit on the issue of obesity? Sometimes it is cheaper to buy frozen and convenience foods than fresh food. Who is responsible for improving that situation? I mean no disrespect to you or the Department, and I am not saying that a commissioner is needed, but whatever you do will be a drop in the ocean until someone says that enough is enough. If the Department for Social Development, the Department of Education, the Department of Culture, Arts and Leisure or the councils cut funding or do not go down the line that we want them to, can the Minister of Health, Social Services and Public Safety go to them and say that enough is enough and outline what they need to do?

Mr A Elliott:

I will respond briefly on a couple of those points. There is no doubt that, in identifying the early-years issue, you highlighted an important component of a range of public health issues that we are trying to tackle. The parts of the developed world that will be quickest and most successful in addressing obesity and noticing a real change will be those that are best at joined-up government. Their Ministers will be able to sit down and work closely together to determine what each of them needs to do to contribute to the overall package. The challenge for all of us is to try to ensure that, by working cross-departmentally, we achieve the most bang for the buck.

There are some positive elements to what is happening in healthcare. In setting up the public health agency, the Minister made it clear that he wants close linkages with local government. He wants the public health agency to be central to community planning and to all the activities that we expect to see local government doing more of in the future, particularly after the review of public administration is complete. That is encouraging and has the potential to tackle not only obesity but a range of other determinants of health.

Mr Phipps:

One of the ironies of obesity is that most of the work upstream is, arguably, conducted outside the Health Service. You put your finger on an extremely challenging issue: for the strategy to work, we must negotiate with all the other Departments, because they each have a role to play. The next year will be interesting as those discussions develop, because we are adopting the approach of asking Departments where they want to be in 10 years’ time. The questions we will ask are: how do we get there and what are the barriers?

Ms S Ramsey:

How do we enforce that? Kieran mentioned guidelines. For whatever reason, Belfast City Council or Omagh District Council may decide not to invest more money into play and leisure facilities. However, a key factor in tackling obesity is ensuring that people exercise. Who makes the councils accountable for making that happen? The steering group includes a representative from the Northern Ireland Local Government Association (NILGA). However, no representatives on the steering group have the authority to say to Lisburn City Council that of the 26 play parks under its control only one is in a nationalist area and that issues of ill health must be tackled, especially in socially deprived areas. However, it seems that no one on the steering group can do that.

Mr A Elliott:

Are you suggesting that we introduce a mechanism to reach all the councils?

Ms S Ramsey:

Yes I am, and I also want the Department’s strategy to be enforced. It is positive that some Ministers have adopted a joined-up approach, but other Ministers need to come into play. Local government is the key to all this, because it provides the leisure centres, the parks, and so forth.

Dr Chada:

That is a very important point. You mentioned the Northern Ireland Local Government Association and its representation on the steering group. Certainly, involving local government is one element. Eventually, we will have to move towards mechanisms through which local people can influence what is happening. Such mechanisms will ensure that local players who are interested in public health can influence decisions locally, which is what you want to see ideally.

We are trying to put some of the building blocks for that in place by encouraging local government, as well as the regional and local elements of the new public health agency once it comes into play, to take a greater interest in public health.

Mr Phipps:

Perhaps one of the ways forward is through PSA targets. One approach could be to have more shared targets. What you spoke about is what we will be grappling with over the next 12 months. Ms Ramsey’s point about securing buy-in is, to a certain extent, one of the challenges that we will have to address.

Mr A Elliott:

We need to think about your point. Essentially, the issue is about how to engage effectively with the local councils and capture their attention. We will take that thought away with us.

Mr Phipps:

The world is changing slightly, and we have to work our way through those changes at the same time.

The Deputy Chairperson:

Community planning will be the key to taking this forward. Therefore, you will need to get that right before anything can get up and running. It is hard to change something that has become embedded. Therefore, we need to tack health inequalities onto community planning from the start. A pilot might be run in one of the areas, so it would be good to monitor that and see how it plays out.

Mrs Hanna:

I certainly agree with Sue; we are all looking forward to the new public health agency and to seeing how well it works across the sectors. In the Assembly, we have a responsibility to work together and to work cross-departmentally, but we do not do that. We do, however, pay lip service to that responsibility, and we know it.

The Committee agreed that it should set up a group on young people and mental health with the Committee for Education to examine school projects and ways of supporting young people, such as coping strategies. We need to do far more on that, and we need to do it formally. For example, what is the Department of Agriculture and Rural Development doing about food labelling? Food labelling might not be DARD’s responsibility entirely, but it is its responsibility to some extent.

What is the Department of the Environment doing about open spaces? In rural areas, there are lovely parks and some great facilities; however, those do not exist in built-up areas. When I was a child, I was chased out of the house to play; now, even my granddaughter and grandson, who are 18 months old, have their own DVDs. In fact, I have been given a DVD for them to watch when they are at my house so that there is no problem. We did not have DVDs when I was young so we had to go out to play. That is part of the problem; however, it is far more than that.

I was a midwife for many years, and I believe that the way to tackle obesity is to focus on prevention and early intervention. Much of that should start at the antenatal clinic, if not before. A mother should be supported and educated about diet and exercise, because, as Kieran said, obesity is certainly connected to lack of exercise.

There has been a cultural shift from simply going outside to play to watching DVDs and sitting around waiting to be entertained. Given that shift, as Sue said, we must involve local government, and I think that it wants to become involved. Councils have some good facilities, but they must engage with people.

I worked on the reception desk of a leisure centre for about a year, and I knew all the people who visited. However, although it was free to attend the leisure centre, the people whom we wanted to visit did not do so. How will we engage with those people and make them visit leisure centres? How do we prevent them becoming obese in the first place? Obesity is an addiction, and, at that stage, it is difficult for people to lose weight. It is not as easy as visiting the GP, asking for help, receiving diet sheets and going on a diet.

I wonder about psychological therapies, because losing weight is very much about people’s frame of mind. I keep mentioning the informal meeting that members had with Dr Michael Ryan, which I thought was fascinating. Those ideas should be incorporated into our strategy on obesity, because they are not currently. It is up to the Assembly and the Department to address that matter.

We all work in silos, and although we talk about the Executive’s poverty strategy, the issue of obesity is linked to poverty and to the widening gap between the haves and the have-nots. We still have the same poverty strategy. In fact, it is a read-across from Westminster, and there have been no changes to it. The Committee for Health, Social Services and Public Safety has a lead role but not a full role, and members cannot address the matter unless we work with other Departments and find the key and the secret to engaging the public and getting the message to the relevant people. That must be done through the community, because many people become engaged in that through peer pressure and peer support.

We have analysed all the issues and have reached certain conclusions. However, we must establish how those conclusions will make a difference. We have not unlocked that matter yet. The only way to engage everyone is through the new public health agency’s working with all Departments and all Assembly Committees. What is the Department of Health, Social Services and Public Safety doing with other Departments? Is it asking questions about green spaces, food labelling and exercise in schools? We must ensure that all Departments play their part.

Mr A Elliott:

The Department has recently been involved with Sir Michael Marmot’s work with the World Health Organization. He also did some work in England to tackle health inequalities. At one of those events, someone told me that, in order to tackle health inequalities successfully, the most important factor is to examine the first four years of life up to the age of three. It is interesting to note that money invested in early years, and before birth, could bring a much greater return on health outcomes on a range of issues.

Mr Easton:

In various ways, obesity costs £500 million a year. That amount of money would represent a good efficiency saving for the Minister, instead of the number of nurses being cut back. However, as Sue and, to a lesser extent, Carmel said, the Health Promotion Agency and sporting initiatives will not make a huge difference. Legislation needs to be changed.

No matter how much exercise schools offer, as soon as it is break time, children go to the tuck shop to buy crisps or Mars bars, which undoes all the good work. School meals are mainly junk food, and, unless we change the law, force schools to offer healthy meals, remove tuck shops, tackle retailers and monitor what ingredients the food producers are using, we will not be effective. In order to make any difference, we need extremely radical proposals.

Mr A Elliott:

We cannot speak for the Department of Education, but that Department would probably say that it has put a lot of energy into the Health Promoting Schools approach and tackling the issue of tuck shops. There have been some real changes. No doubt there are still some examples of poor practice, and the Department has started to focus on that issue.

Mr Phipps:

Schools have new nutritional standards, and changes have been made to make them more rigorous. Schools have also been able to increase the amount of money that they can spend. Work has been done.

Mr Gardiner:

There are also breakfast clubs, which promote healthy eating.

Mr Easton:

No one denies that, but I am suggesting that it does not go far enough. We need something totally radical in order to make a difference.

The Deputy Chairperson:

We intend to invite officials from the Department of Education to discuss that further with the Committee.

Ms S Ramsey:

I agree with Alex, and I know what Sam is talking about; it is about changing a mindset. Not so long ago, there was a row in the Assembly about whether the Department of Health, Social Services and Public Safety or the Department of Education was funding the breakfast clubs and after-school clubs. It is about changing Departments’ mindsets. The will is there, but we need to change the mindset of civil servants. Instead of cooking the books, we must ensure that we are cooking the right stuff.

Mrs McGill:

I have a question about children and young people in relation to the graph and some of the figures that you have presented on pages 3 and 4 of your written submission. The figures date back to 1997 and 1998, and there are also some figures for 2004 and 2005. However, the rest of the graph relates to possible trajectories. There is a gap from 2005 until now.

Mr Phipps:

Those figures need to be updated.

Mrs McGill:

That is a bit out of date. The graph is an illustration of possible trajectories, but it would have been better to have a more up-to-date analysis of the situation in relation to children and young people.

As a personal observation, I do not see obesity in young children when I meet them. I read your figures, but I do not actually see evidence of obesity, although, obviously, what I see is limited.

Mr Phipps:

That is interesting, because research has been carried out into parents’ views of their own children, and many parents cannot see that their children are overweight, although the figures suggest that they are; there is a perception that parents do not always recognise their children being overweight.

Adults and parents do not always see the link between being overweight and ill health, as Dr Chada pointed out. They think that a child may be overweight but that he or she is still healthy. People’s perceptions are an issue. Awareness must be raised of the health risks associated with obesity. Your point is absolutely valid.

Mrs McGill:

That is not really my point. When I see groups of young people — and many visit this Building every day — I do not look out to see who is obese and who is not, but I do not see such levels of obesity.

Mr A Elliott:

Only 5% of children are obese, but a higher percentage of children’s BMI is not at a healthy level. Perhaps that is not as obvious in a group of people wearing blazers.

Dr Chada:

There are two issues here. First, as Rob and Andrew pointed out, the prevalence of children who are overweight or obese is much lower than it is in the adult population. Secondly, as Rob also said, it is a matter of perception and norms. Over time, people have been getting heavier, and there is a higher prevalence of people who are overweight or obese. Therefore, what we now consider to be normal might not have been considered to be normal 20 or 30 years ago. Therefore, there are many subtle issues that point to how we perceive matters.

The Deputy Chairperson:

You said that the statistics here are not dissimilar to other areas. Have you examined how successful other countries have been in tackling the problem? Perhaps you could share with us success stories and good practice elsewhere?

Mr Phipps:

I attended an EU meeting recently, and it was fascinating to hear about all the countries that we assumed would not have had an obesity problem. For example, Italy is very concerned about obesity, as are Spain, Portugal and the Czech Republic. Interestingly, the Czech Republic has great difficulty in getting young people to eat traditional Czech food. Therefore, it is the same issue — it is about the globalisation of food patterns.

Sweden has had some success, and it has seen a reduction in obesity among young people, but it has been honest in saying that it does not know the reason for that. Nevertheless, it has seen a slight decline.

A programme called Ensemble, Prévenons l’Obésité des Enfants (EPODE), which means “together, we can prevent obesity in children”, has been implemented in France and Belgium, and it focuses on the local community. England is considering adopting a similar programme called Healthy Towns, which takes a community-driven approach to tackling the problem.

Therefore, there are some examples of good practice, but, interestingly, much of Europe is saying that there is a problem, and we are not too sure how to address it. People want to find the best way forward, and the approach that we propose to take is one that Holland and other countries are keen to follow. Therefore, other people are thinking of taking the approach that we are taking, so we are almost leading in the overarching obesity framework.

The Deputy Chairperson:

Finally, the Health Promotion Agency’s submission to the Committee stated that its weight management clinics are not consistent across the North and that access varies depending on where people live. Do you have any comments on that?

Mr Galloway:

That is the situation. In response to Mr Buchanan’s question, GPs can refer people to activity programmes, which are delivered in leisure centres. However, that is not universal. Therefore, there some work to be done to ensure that the services are available so that people can be referred and can receive advice and information about how they could better manage their weight.

The Deputy Chairperson:

Obviously, consistency is important.

Mr Galloway:

Consistency is the issue. Over time, the four boards have taken different approaches to issues in their own areas, so the situation has developed in slightly different ways in the four board areas.

Dr Deeny:

What does PSA stand for?

Mr A Elliott:

It stands for public service agreement.

The Deputy Chairperson:

Thank you very much for coming along.

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