Select Committee on Health Second Report


165. Numerous witnesses, in written and oral evidence, told us about the problems of a 'bidding culture' in regard to public health initiatives. As we have seen, a raft of recent public health and regeneration initiatives are funded by a competitive bidding process. In principle this sounds sensible, but in practice, there are a number of problems.

166. Bidding for funding diverts valuable resources from the project itself. This is not helped by the application processes which seem to be equally lengthy and complex whether the sums applied for are large or small. Each bid made requires its own lengthy administrative process and staff time to write the bid and wait for the response, causing a delay in the development of the project.

167. This is exacerbated by the multiplicity of funding sources. This means agencies are obliged to be constantly engaged in identifying and applying to different sources, which multiplies the administrative time required, and therefore cost, even further.[210] This raises another problem, that of conflicting priorities, both of the different funders (as we have described above) and between the bidder and the funding source. Most of the witnesses believed that the bidding processes distorted local priorities.

168. The bidding culture also fosters a sense of competition which is neither appropriate nor useful in the context of community regeneration. Given that government policy in this field is organised around developing partnerships, the competitive ethos of the bidding process has a rather perverse effect. The intimidating nature of the bidding requirements may in part relate to the status of public health in the DoH: as one witness told us, "when you have a waiting list pot [of money] you do not have to say very much to get quite a lot of money, and you have to say an awful lot ... for a little bit of public health money". In fact, it is sometimes easier to secure regeneration funding for public health initiatives than to access mainstream health funds.[211]

169. The evidence we evaluated suggested that problems in the funding of public health programmes arose from short-termism. Many public health problems require mid to long-term work to produce qualitative outcomes which are often hard to measure. Building local capacity and, therefore, sustainability, is key in any community intervention and this requires time and continuity. This means that any initiative to deal with them needs secure, long-term funding. There seems to be a problem with turning short-term pilots which are effective into mainstream, long-term projects which can deliver real benefits. This is particularly true for charitable organisations, which seem to be prevented from progressing from short- term funding to reliable long-term support, creating unnecessary insecurity.[212] We also came across this problem in our inquiry into NHS mental health services.[213]

170. This lack of security has implications for involving local communities, which, as we have suggested, is a crucial factor in ensuring ownership of the process, and thus the ultimate success of the initiative. Professor Popay explained to us how vital local involvement was to building a sustainable public health intervention, and how this was impossible to secure meaningfully in the context of the bidding process. She also pointed out that local people would probably not have the skills to take part in such a process.[214]

171. Finally, even when the decisions are made and funding allocated, it has been felt that the successful projects came from those, not in greatest need, but those most able to write a plausibly argued and convincing bid - who are unlikely to be the hardest pressed given the staff time and effort required to make bids. Moreover, it has even been suggested that decisions over where money should go have been made even before bids have been received, raising the question of why the bidding process is necessary in the first place.[215]

172. All of these problems described are amplified for charitable or voluntary agencies, because they cannot expect to have the security which would allow them to take on more staff to co-ordinate bids to different funding sources.[216] These agencies may also find it more difficult to identify the different government funding streams and keep up to date with changing arrangements and structures.

173. It is always difficult to allocate money fairly when resources are limited, but the bidding process as a method of distributing funds seems to us to work particularly badly in this field. However, a few modifications of the current system might help enormously. One of our witnesses suggested having a two tier system by which to filter out some applications using a brief format before requiring those left to construct much more detailed bids. That way, fewer people would waste effort and bids might even be speeded up. Agencies could also be invited to form consortia and bid together.[217]

174. In the end, however, we agree with Ken Jarrold, Chief Executive, County Durham and Darlington Health Authority, who told us that we needed three things:

"First of all, we need a robust formula for allocating resources on a population basis that takes adequate account of deprivation. The new DETR index is a very powerful way into that and I think it really is important to look at that. If we had resources allocated fairly on a population basis with both health and local authorities taking account of deprivation, there would be no need for these endless bidding processes. Secondly, though, of course it is right for government to set out its expectations of how we use that money very clearly and, thirdly, to hold us to account. If they did those three things we could much more effectively deliver rather than spending a lot of time and energy on bidding processes which are not the most effective way of distributing resources. "[218]

We recommend that the Government adopts population-based funding and clear policies for its application and then leaves it up to local agencies, as part of the HImP, to get on and deliver on these policies with the appropriate training in place to equip managers and others with the requisite skills. At the very least the bidding process needs to be reformed. We recommend that the Government conducts a review of the bidding process in the context of public health funding, with a view to formulating a more equitable system for the allocation of money, particularly in regard to voluntary or charitable organisations.


175. Sir Donald Acheson and his co-authors, in their Independent Inquiry into Inequalities in Health, drew attention to the importance of pre and post natal health of infants and mothers as indicators of adult health:

"Reduced growth in foetal life is associated with increased mortality and morbidity in the first year of life, and throughout childhood. People who had low birthweight, or who are thin or stunted at birth, are at increased risk of cardiovascular disease and the disorders related to it in later life ... Birthweight is determined by the weight and height of the mother, which in turn reflects her own growth in childhood. The physique of mothers is also related to later disease in children."[219]

In oral evidence, Sir Michael Marmot also described to us how the incidence of certain diseases is dependent upon health in childhood;[220] the second recommendation of the Acheson report advised, "We recommend a high priority is given to policies aimed at improving health and reducing health inequalities in women of childbearing age, expectant mothers and young children".[221]

176. It is clear that special attention should be paid to the health of children. This involves pre-natal health, pre-school interventions (which are the domain of Primary Care) and, over a longer period, care at school. To quote the WHO, "the determinants of both education and health are indivisibly linked ... there is a dynamic which cannot be ignored if we are to protect, sustain and enhance the education and health of our young people ... the development of the educational potential of the school health services must go beyond routine screening".[222] Yet as we discuss below, obesity in children in the UK is on a sharply rising trend with a great consequential threat to their future health.

177. What is also clear is that the health of children today in the UK is not good, and it appears to be getting worse. For example, 8 per cent of British 4 year olds are now obese - as are 17 per cent of 15 year olds - and obesity among children is on a sharply rising trend, with all the health implications that that entails (see below paragraph 190).[223]


178. The health of school age children is an area which impinges on the territory of several government departments, and as such is a particularly fertile ground for cross-departmental work. The involvement of the DoH in such work is largely concentrated on the Healthy Schools Programme, a joint initiative with DfEE. The main plank of the Healthy Schools Programme is the Healthy School Standard which is a national accreditation scheme to encourage and validate local strategies for improving health in schools. The onus is on local education and health authorities, in collaboration with schools and the local community, to develop their own plans for improving health in schools, using all aspects of school life, including the curriculum (particularly Personal, Social and Health Education) the physical environment of the school, the nutrition policy of the school and the time spent in physical activity by children. Health authorities and local authorities are required to involve statutory and non-statutory agencies, work with those providing services to schools such as school nurses, and set up within schools a school co-ordinator and task force with clearly defined roles in the developmental process. Accreditation to the National Standard is dependent on meeting certain standards, sensitive to numerous indicators and rates of improvement of a school's performance. The emphasis is on a 'whole-school' approach in which all aspects of school life give consistent messages about healthy living, and on consultation and co-operation with all involved in school communities, including pupils, teachers, parents and school nurses, at strategic and operational level.

179. The school co-ordinator is an important link with other agencies, and the programme has been developed to link with and support relevant policies from other government departments such as DETR on the scheme 'Safe Travel to Schools', and MAFF and the Food Standards Agency on diet and nutrition issues, including the National School Fruit Scheme.[224]

180. An important element of this work should be the amount of physical activity undertaken by children. Physical activity in childhood is an important contributor not only to childhood health but also to health in later life. Mr Len Almond of the British Heart Foundation made clear to us that, although the evidence on the importance of physical activity to health has been for many years difficult to establish, research evidence is now very strong.[225] With this in mind, it is evident that the Government should be working hard to engage children in physical activity. Indeed, the Healthy Schools Standard "sets out an expectation that pupils should have a minimum of two hours physical activity a week".[226] However, a MORI survey commissioned by Sport England and released earlier this year, shows a sharp decline in the amount of physical education at school received by children over the past five years. The proportion spending two or more hours in PE lessons each week fell from 46% to 33% between 1994 and 1999.[227] In 1999, moreover, only 21% of primary schools were able to achieve the Government's target of two hours of PE a week.[228] It is evident that bringing schools up to this target will take more than "expectation".

181. In the area of physical activity, the DoH and DfEE are not the only departments with an interest in the health of school children. The Department for Culture, Media and Sport (DCMS) has a Public Service Agreement to raise the average time spent on all sport and physical activity by those aged between six and 16 from the present level of eight and a half hours per week, to nine hours a week by the end of 2004. DCMS is putting in place an army of 1000 Schools Sports Co-ordinators to try to engage secondary schools "in communities of greatest need" in a wider network of sporting activity.[229]

182. What is slightly unclear is how the various activities of DoH and DCMS, pivoting on DfEE, complement each other. It is to be hoped that the Schools Sports Co-ordinators will link into the Healthy Schools Programme and that the latter will link into related DCMS initiatives: however it is not clear that this will be the case, and the potential to duplicate effort and waste a lot of public money remains. The Minister for Sport, Kate Hoey, told us, "I am very aware that I think the next area of real concentration of co­operation has to be with the Department of Health",[230] rather implying that the two departments have not had a good history of co-operation.

183. It would seem that both DoH and DCMS have good strategic links with DfEE, and this joint working might provide a model for the development of relations between DCMS and DoH. The DCMS website describes how "the Department of Culture, Media and Sport is working closely with the Department for Education and Employment (DfEE) to ensure a co-ordinated approach to the provision of both curriculum PE and after-school sporting activity"[231] but does not mention DoH activities at all. DfEE and DCMS have appointed a joint adviser specifically to liaise between the two departments and it may be that DOH and DCMS need similar links. We discuss below ways in which the work of DoH and DCMS could be better co-ordinated (see paragraph 198).

184. Several witnesses brought to our attention the importance of involving children themselves in judging their health needs and useful health interventions.[232] Mr Kelly from Hillingdon told us that actually doing this was "an extremely difficult area";[233] it seems, however, that it is a very important one. We recommend the Government does more to research and involve the views of children in initiatives aimed at improving their health.


185. As health professionals located in the setting of schools, school nurses are key to delivering public health messages at school. Saving Lives: Our Healthier Nation (1999) affirmed the importance of the school nurse as public health worker, and the Government's strategy document on nursing, midwifery and health visiting, Making a Difference (1999) stated "We need to develop the public health role of the school nurse too, building on the opportunities their contact with children and young people provide".[234] Since Saving Lives, there has been a shift in the role of the school nurse away from the provider of universal screening programmes and towards a more strategic public health role. Mr Kelly of Hillingdon described the role of the school nurse in the context of the Healthy Schools Programme as "a health adviser to the school and a link to other agencies; someone who can coordinate input into the school; can advise the school on the development of health in total, not just health services".[235] As such the school nurse would be involved in carrying out health needs assessments of school child populations and formulating strategies to improve the health of those populations. It is vital that school nurses should be able to access and collaborate with PCG/T structures, the developers of the Healthy Schools Standard, and contribute to the Health Improvement Programme.

186. School nurses remain, however, an under-developed resource. In addition to the recruitment problem common to the whole nursing profession, the CPHVA has brought to our attention the difficulties posed by the diverse employment structures of school nurses. These militate against effective communication and joint-working: some school nurses are acute based, some are based in education and most are located in primary care. The CPHVA argue that the function is best placed within PCTs. We recommend that the employment structures of school nurses be rationalized so as to allow effective joint working and partnerships.[236]

187. School nurses could also be used more effectively if they worked more flexibly. Ms Jackson of the CPHVA pointed out to us that "one school does not necessarily have to receive the same service as other schools; it should be based on need". Health assessments conducted by school nurses and others would allow skills to be targeted to areas of greatest need. School nurses could also develop a more holistic service if they worked all year round, instead of part-time in term-time only, which is how most currently work. "Children and young people have lives outside of schools and that is where obviously lots of issues occur and where there is also a need for the service".[237]

188. The Report of the CPHVA, The Queen's Institute and RCN, School Nursing Within the Public Health Agenda (A Strategy for Practice) makes several recommendations for the development of the school nursing service. We would endorse their suggestions that:

  • assessments of health need of schools and local communities should be carried out collaboratively by school nurses and primary care teams, the Director of Public Health and other agencies. The HImP can also be used as a vehicle for such collaborative assessments;
  • school nurse education and training would benefit from revision in order to allow a greater focus on public health;
  • there is diversity across the UK in the school nurse/pupil ratio. Some specifications about what constitutes an ideal service size need to be developed.

We recommend that the Government should support and consult the professional bodies to develop the school nursing service as a vital public health role. We also think it would be beneficial if this service could be integrated with other public health workers in the community.


The Epidemic of Obesity

189. Obesity is most commonly defined as a body mass index (BMI) above 30 where the BMI is calculated by dividing an individual's weight in kilogrammes by their height in metres. Adopting the same calculation, an individual with a BMI in the range 25 to 30 is generally classified as "overweight".[238] According to a recent detailed analysis produced by the National Audit Office (NAO) and agreed with the relevant Government departments, Britain is experiencing a rapid and worrying increase in the extent of obesity.

"In 1998, the year for which the most recent figures are available, 19 per cent of adults were obese, with a BMI over 30. More women than men were obese - 21 per cent of women compared to 17 per cent of men. But more men than women were in the overweight category (BMI between 25 and 30) - 46 per cent compared to 32 per cent. Combining the overweight and obese groups, in 1998 nearly two thirds of men and just over half of women were either obese or overweight."[239]

This in itself we find most disturbing but what makes the figures particularly stark is the extraordinary rate of increase over the last two decades. In the words of the same NAO report, "The prevalence of obesity in England has almost tripled since 1980 and will increase further on present trends", and obesity is increasing more rapidly in England than in other parts of Europe.[240]

190. More worrying still is the huge increase in obesity amongst children. Data from a recent representative sample of 2630 English children showed that the frequency of overweight children ranged from 22% at age 6 years to 31% at age 15 years.[241] Another study by the same authors has suggested that the number of obese six year olds has doubled in the last ten years and the number of obese 15 year olds has more than trebled.[242] Fewer than 20% of 2-15 year olds eat fruit and vegetables more than once per day and the typical diet of children and adolescents is rich in fat, sugar and salt. Again there is a link between social class and diet: "Among boys and girls aged 2-15 there is a decrease from social classes I/II to IV/V and from higher to lower income households in the proportion consuming fruit and vegetables with a related increase in the proportion consuming sweet foods, soft drinks crisps and chips".[243]

191. Diet is one key determinant in the rise of obesity in youngsters: another is a decline in the amount of physical exercise. In May 2000 the British Heart Foundation published an analysis of physical activity in children. This found that schools in England allocated less time to PE than anywhere else in the EU according to the last survey which was conducted in 1994.[244] Since then things have deteriorated: the percentage of children spending two or more hours per week on PE has fallen from 46% to 33%. In many EU countries, such as Austria, Norway, Portugal, Spain and Switzerland the average time spent is 3.5 hours and in France and Germany it is three hours. This is part of a general trend towards sedentary rather than active behaviour amongst the population aged five to 18. Between 1986 and 1996 the proportion of 17 year olds walking to school fell from 59% to 49%. Only 1% of children now cycle to school, whilst the number of children travelling by car has doubled in the last 20 years. Active play amongst children is being superseded by time spent watching television or playing computer games. Nearly three quarters of 11-16 year olds watch television for two hours a day and 10% of children spend the same amount of time on the computer. The Yorkshire Post recently ran a campaign "A Sporting Chance" to draw attention to the decline of sport in schools. Amongst the evidence they recorded was that:

  • a third of primary schools have reduced the time for PE during the last school year
  • some 95% of primary schools have no full-time PE specialist
  • children spend twice as much time watching television and playing computer games as they do in playing sport or otherwise taking exercise.

They contacted 400 teachers in Yorkshire to ascertain their views on the state of sport in school and found that 55% of respondents were either "pessimistic" or "very pessimistic". Moreover 88% said that pressure on the curriculum time arising from the emphasis on maths and English was "a major factor" in the decline of school sports.[245]

192. The situation amongst adults is also bleak. A 1990 survey jointly conducted by the GB Sports Council and Health Education Authority found that the activity levels at that time recommended by the then HEA were not being met by seven out of 10 men and eight out of 10 women.

193. Health inequalities are mirrored in inequalities in access to, and take up of, active leisure. In a recent article, Professor Sally McIntyre has suggested that facilities encouraging healthy lives are poorer in places where people are poorer, a process she describes as "deprivation amplification".[246] In addition, fewer residents have access to cars and public transport in less affluent areas, so accessing sporting activities becomes a less attractive option. In analysing the demographic distribution of obesity the NAO found that obesity was higher in lower socio-economic groups: 14% of women in Social Class I were classified as obese against 28% in Social Class V.[247] Obesity was also more prevalent in certain ethnic groups such as Black Caribbean and Pakistani women.[248]

194. The consequences of the decline in physical activity and increase in obesity are alarming. The NAO notes:

"Obesity is an important risk factor for a number of chronic diseases that constitute the principal causes of death in England, including heart disease, stroke and some cancers. It also contributes to other serious life shortening conditions such as Type 2 diabetes. As well as physical symptoms, the psychological and social burdens of obesity can be significant: social stigma, low self esteem, reduced mobility and a generally poorer quality of life are common experiences for many obese people."[249]

The NAO estimates that over 30,000 deaths were attributable to obesity in 1998, that the treatment of obesity cost the NHS at least £500 million in that year, and that the indirect costs of obesity in terms of lost output in the economy due to sickness or death of workers is around £2 billion a year at present and likely to rise to £3 billion by 2010.[250]

195. The White Paper Saving Lives describes physical activity as "one of the key determinants of good health".[251] Summing up the available research the Acheson Report on Health Inequalities concluded that:

"Increased physical activity is associated with lower overall mortality rates and decreased risks of mortality from cardiovascular disease, colon cancer and non-insulin dependent diabetes mellitus. Regular physical activity prevents or delays the development of hypertension ... Physical activity also relieves the symptoms of depression and anxiety and is important in the prevention of osteoporosis."[252]

The Sports Minister cited evidence to suggest that "an active child is ten times more likely to be an active adult"[253] thus radically reducing the risk of chronic diseases of adulthood.[254] Research has amply demonstrated that physical fitness in children has benefits beyond the purely physiological: it reduces stress and anxiety, promotes optimal development and enhances self-esteem.[255] Mr Bob Laventure of the British Heart Foundation suggested that the benefits of physical activity were not confined to children and young adults. Whilst the ageing process inevitably involved a decline in functional capacity he told us there was "a vast amount of evidence ... that physical activity can play a major part in either slowing that decline, or even, with types of programmes, reversing the decline".[256] As well as the physiological benefits, such as decrease in the risk of falls, there were the psycho-social benefits arising from greater independence to elderly people as a consequence of higher levels of mobility.

196. The memorandum from Sport England argued that sport could yield even wider benefits: they reported an OFSTED finding that schools "which take sport seriously generate faster-than-average improvements in academic results". They also noted that employers have found that employees taking regular exercise have less time off in sickness leave. A US study suggested that inactive members of the community incurred medical costs 30% higher than for those leading active lives.[257]

197. Saving Lives described the "marked growth in the number of people taking part in sport as a significant feature of life for many people now".[258] Perhaps the vagueness in this sentence is significant, because it appears to be contradicted by other evidence. Sport England pointed to a "number of different surveys, conducted over the last ten years" which suggest that British people lead "increasingly sedentary lives".[259]

198. We wanted to establish what the Government was doing about the major threat to public health posted by obesity and sedentary lifestyles amongst children and adults. In particular we wanted to establish the extent to which Government was co-ordinating its efforts in seeing sport and exercise as part of the health agenda. We asked if DCMS had had an involvement in drawing up the Mental Health White Paper or the moves towards Primary Care Trusts. Mr Harry Reeves, Head of the Sport and Recreation Division, DCMS, conceded that on these specific issues DCMS's involvement was "very small".[260] He felt that his Department had in the past been good at identifying areas where their work directly cut across that of another Department (for example, anti-doping in sport) but less good in areas where the connection was more indirect. He did, however, suggest that work was in progress to improve the connection. The Sports Minister herself conceded that co-ordination between Health and Sport had not always been optimised. She noted that her Department had a shared adviser with the DfEE which had greatly improved inter-departmental co-ordination. She felt that there might be merit in a similar appointment to co-ordinate DCMS and DoH. We agree with this principle and would indeed go further. We note how in countries such as Cuba and Australia the sporting agenda is seen as part of a much wider health and regeneration agenda. We believe that better liaison is essential between all Government departments-notably DCMS, DfEE, DETR and DoH-if this is to be achieved. Accordingly we recommend that the Government appoints advisers specifically to co-ordinate the work of all Government departments to deliver the sport and health agenda as a matter of urgency.

199. We also wanted to establish whether DCMS itself was an appropriate location for the sport function in central Government. Throughout the EU sport finds itself in an extremely wide range of different departments, as the following table indicates:


Body responsible for sport


Federal Chancery allocates grants but each region has autonomous responsibility for the administration of sport


Ministry of Consumer Affairs, Public Health and the Environment


Ministry of Cultural Affairs


Ministry of Education


Ministry of Youth and Sport


Ministry of the Interior


General Secretary for Sport who co-ordinates with other departments


Department of Tourism, Sport and Recreation


Autonomous body CONI has financial and administrative responsibility but is subject to "vigilance" by the Deputy Prime Minister


Ministry of National Education, Vocational Training and Sport


Minister for Public Health, Welfare and Sport


State Secretary for Sport answerable to PM


Ministry of Education, Culture and Sport


Ministry of Public Administration

Source: Europa Year Book. In addition, most countries cede responsibility for sport in schools to the Ministry of Education.

The sheer range of departments points to the lack of an obvious location for an activity which is central to the lives of many of Europe's citizens but at the margins of Government in terms of activity and expenditure: Mr Reeves from DCMS told us that, within his department, only 25 civil servants had responsibility for sports policy.[261] Mr Reeves felt, however, that it was better for sport to sit within a small department, where it attracted more attention, than in a department where there were more evident "policy links".[262] The Minister told us that if she had " a blank sheet of paper" she would not have organised sport in the way it was now organized, but she felt that the disruption that would be caused by a further organizational upheaval outweighed any possible benefits of such a move.

200. We are not convinced that DCMS is the appropriate ministry to have responsibility for sport. We think it perpetuates the notion of sport as a matter for spectators rather than participants. We were impressed by the example of Cuba, where sport is treated as intimately bound up with the public health agenda. We think that sport, like public health, needs greatly to strengthen its profile across Government. We would also point out that the Minister's justification of leaving sport where it is (that it attracts more attention in a small department) completely contradicts the Public Health Minister's argument for retaining public health in the DoH (that it carries more weight as part of a big department-see below, paragraph 235). However, we accept that immediate reorganization may be unwelcome, and would urge the Government to keep under review the location of sport in Government, with a view to creating much closer links with public health. As an interim measure we recommend that the Minister for Sport should become a full member of the key Cabinet Committee on health policy, the Ministerial Committee on Home and Social Affairs (Health Strategy).

201. We now turn to the issue of how sport and exercise can be part of the health improvement agenda. At present the Health Development Agency recommends that everyone should participate in 30 minutes of moderate intensity exercise (such as brisk walking, heavy gardening and heavy housework) on at least five days a week.[263] The target used to be for three periods per week of 20 minutes of intense activity but the current guideline was issued by the DoH in 1996. Professor Stuart Biddle of the British Heart Foundation told us that the recommended levels of exercise had been shown to be "very beneficial"physiologically but was also "behaviourally" a good target in that it was less intimidating than the previous targets.[264]

202. The target might in itself be good, but it will be useless if nobody knows about it or acts upon it. Here we encountered some disturbing evidence. Mr Len Almond of the British Heart Foundation, drawing on Health Education Authority research told us, that only 27% of the general public recognized the targets and, more alarmingly, only 11% of GPs.[265] Exercise on prescription is one way of making the link between primary care and health promotion. No central statistics are held on the extent of GP referrals, but according to the NAO's survey "14% of general practitioners and 33% of practice nurses referred patients to a trained exercise specialist or specific exercise programme".[266] In a recent Written Answer the Public Health Minister referred to a Health Education Authority study of GP referral exercise schemes which suggested that "better designed schemes can lead to small levels of increased participation, but that practice across the country was highly variable".[267] In June 2000 the DoH announced plans to publish new guidelines to help general practitioners start exercise on prescription schemes. They have commissioned experts in health and physical activity to produce a National Quality Assurance Framework for Exercise Referral Schemes.[268]

203. The NAO research pointed to a general lack of awareness of the scale of the problem of obesity throughout the health service. They found that only around half of GP practices made information available to all patients about the risks of obesity, and that only 40% of practices "attempted to identify those patients at highest risk of excessive weight gain".[269] The NAO concluded that there may be benefits if more GP practices were more active in educating their patients on obesity, and we would endorse their conclusion. The DoH has funded the dissemination of the report jointly produced by the Faculty of Public Medicine and Royal College of Physicians, Tackling Obesity - A Toolbox. But the NAO found that, although most health authorities had identified obesity as a health risk in their Health Improvement Programmes only 34% of those surveyed had identified obesity as "a local priority".[270] We believe that the rapid growth in the extent of obesity poses a major public health hazard and that all health authorities should regard it as a first order priority. We hope that the publication of the National Service Framework will encourage health authorities to take prompt action and recommend that the Department should monitor health authorities' activity levels and strategies in this area as a matter of urgency.

210   Q575. Back

211   Q537. Back

212   Q538. Back

213   Fourth Report of the Health Committee of Session 1999-2000, The Provision of NHS Mental Health Services (HC 373), para 104. Back

214   Q63. Back

215   Q537, Q571, Q576. Back

216   Q537. Back

217   Q575. Back

218   Q421. Back

219   Independent Inquiry into Inequalities in Health, p.69. Back

220   Q130. Back

221   Independent Inquiry into Inequalities in Health, p.31. Back

222   School Nursing within the Public Health Agenda: a strategy for Practice, (CPHVA, The Queen's Institute, RCN), p.11. Back

223   Ev., p.260. Back

224   Ev., p.511. Back

225   Q582. Back

226   Ev., p.510. Back

227   Ev., p.259. Back

228   Q595. Back

229   A Sporting Future for all, DCMS 2000, p.32; Official Report, 9 February 2001, c704w. Back

230   Q628. Back

231  Back

232   Q171. Back

233   Q529. Back

234   Cited in School Nursing within the Public Health Agenda, p.7. Back

235   Q535. Back

236   Ev., p.194. Back

237   Q482. Back

238   Tackling Obesity in England, National Audit Office, (HC220, Session 2000-2001), p.11. Back

239   Ibid., p.11. Back

240   Ibid., p.12. Back

241   John J Reilly and Ahmad R Dorosty, "Epidemic of obesity in UK children", The Lancet, vol.354, no. 9193 November 1999. Back

242   Reilly, Dorosty and PM Emmett (1999) "Prevalence of overweight and obesity in British children: cohort study", BMJ, 319:1039, cited in Couch KidsBack

243   Couch Kids, p.6. One factor that may encourage children to have a poor diet is sponsorship by food and drink companies within schools. Back

244   Couch Kids, p.3. Back

245   Ev., p.470. Back

246   "The Social Patterning of Exercise Behaviours: the Role of Personal and Local Resources", Journal of Sports Medicine, February 2000, Vol. 34 (1), p.6. Back

247   Tackling Obesity in England, pp.52-53. Back

248   Tackling Obesity in England, p.53. Back

249   Tackling Obesity in England, p.14. Back

250   Tackling Obesity in England, pp. 16-17. Back

251   Saving Lives: Our Healthier Nation, 1999, p.25. Back

252   Inequalities in Health, p.82. Back

253   Q645. Back

254   Couch Kids, p.2. Back

255   Couch Kids, p.2. Back

256   Q617. Back

257   Ev., pp.259-60. Back

258   Saving Lives, p.25. Back

259   Ev., p.259. Back

260   Q631; Q634. Back

261   Q631. Back

262   Q631. Back

263   See HDA document, Coronary Heart Disease, Guidance for implementing the preventive aspects of the National Service Framework, 2000, p.43. Back

264   Q593; Q591. Back

265   Q594. Back

266   Tackling Obesity in England, p.23. Back

267   Official Report, 21.12.2000, col.281w. Back

268   Tackling Obesity in England, p.24. Back

269   Tackling Obesity in England, p.22. Back

270   Tackling Obesity in England, pp. 19-20. Back

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