Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 140 - 159)



  140. Your Department and indeed GPs are absolutely central. I am going to go back to that earlier figure which was that only about 40 per cent of GPs actively identify patients at risk of excessive weight gain. You quite rightly said that the report acknowledges the deficit in terms of information in the past. I am not really sure yet what it is that you are planning to do to address that deficit. It is one thing to have a report which tells us there is a deficit. What are you planning to do to address it?
  (Mr Crisp) At the moment it is a whole lot of individual things. There are some guidelines and as part of those guidelines we are actually looking at whether we should update some of the current guidelines. They are not comprehensive so we are looking at some to see whether or not we should update them. We have also provided for the first time—and it was published last week or the week before—guidelines on referrals for physical exercise. That may sound a terribly simplistic thing but one of the issues for GPs was whether or not, when they referred people for physical exercise, they took liability for that. What were the liability issues. Our guidelines actually address those sort of points. We are gradually putting in place a battery of different initiatives to tackle the problem.

  141. If GPs are so important, which they are, how can you deliver a strategy which gives such importance to GPs when GPs are by and large overworked? This strategy takes time and expertise and the report is not clear that GPs have either.
  (Mr Crisp) You are absolutely right; there are competing demands which people have to make decisions about in terms of how they are actually using their time locally. That is the point about having what we call health improvement plans in every neighbourhood which are actually precisely about saying what the issues are here. They will be quite different in different parts of the country. You will have seen in this report that there is a regional aspect to obesity. You will also see that there is an ethnic aspect to obesity. You will see in some communities that this is a much bigger issue than it is in other communities. Therefore the health improvement programme is the bringing together of all the programmes for health in the locality into a balance.

  The Committee suspended from 6.15 p.m. to 6.25 p.m. for a division in the House.

  142. You were talking about updating guidelines and a whole series of things. We also have health action zones and you told us that health authorities have action plans and all sorts of different ways of delivering this national strategy. Is there not a danger that the Department of Health is too far removed from where this strategy is actually being delivered?
  (Mr Crisp) We need to do the strategic things and then let people get on with it locally, if that is the point you are making. What I did not say earlier, and perhaps it should have been more important that I said it earlier, is that NAO survey was done before we put in place the coronary heart disease National Service Framework, so things have probably moved on. One of the other strategic things we have done is increase the number of GPs and are investing to have more GPs. Those are the sort of things we should be doing at a distance, but making sure that locally people pick it up as a priority and make the decisions which are relevant to their local community.

  143. Are you very carefully monitoring what is happening locally and ensuring that they are hitting the targets they have been given and that the targets are stringent enough?
  (Mr Crisp) We are starting to do that but the first stage of that is that we are getting an assessment by the Health Development Agency of the local plans, precisely because it is starting and we are making an evaluation of them and making sure that we understand what those plans are and can spread good practice and so on as part of the monitoring. It is not just a collecting-ticks-in-the-box monitoring, it is about making sure that local people can learn from other local people through the spread of good practice.

  144. I very much hope it is successful. I am struggling not to be sceptical about this. You spoke earlier about the link and the report speaks of the link between affluence and obesity. Is there not also another important leap between affluence and the solution to some of this? For example, the quality of food people have access to, or access to gymnasia, or the kind of people who cry out for cycle routes, or the kind of people who use sports centres?
  (Mr Crisp) Yes. If you look at the data given in this report on the inequalities issues, you will see that they particularly apply—

  145. I think the point I am getting at is how do you know that the strategy is getting at the people it needs to get at, because if it is not, the taxpayer is not getting value for money?
  (Mr Crisp) That is the point of some parts of the overall approach which includes the school fruit approach. Those are about making sure that they get to everybody and not just to the people who may be influenced by health promotion campaigns.

  146. But we have already heard about the emphasis which quite rightly is being put on school children and the education of school children. I applaud the pilot to provide fresh fruit in schools. But what happens if fresh fruit is not part of the shopping list of that family or many of the families in that area?
  (Mr Crisp) Yes and that is where you do produce educational processes for adults as well as for children. If you look at the sort of things GPs are saying they want help with, they want help with some of those sorts of things which support people in dealing with obesity, more self-help groups, more information, more support for patients, more support for people, the ability to make referrals for exercise and so on, so they can perhaps persuade some people who might not otherwise be using sports facilities to go to use sports facilities.

  147. I suppose what I am getting at is whether the emphasis on children, which perhaps is not as great as I have been led to believe, means that other people are not being given the priority and these are the very people, the parents, who will be the role models for the children who are eating fruit and exercising at school, but that is not happening at home.
  (Mr Crisp) There are several community initiatives to promote fruit and vegetable eating as well and purchase, so there is some support for it. The wholesale activity is happening in schools and the wholesale activity is about promotion and prevention, whereas more typically the work with adults is around people who are already overweight. That is more typically where the emphasis is at the moment. The point you make about needing some adult education and support in there as well is well known.

  148. Let me turn very briefly to schools and go back to the debate as to whether or not local authorities should have the statutory requirement to provide sports facilities. Why is it, or is it just my imagination, that every fairly minor French town seems to have a good running track and a football stadium and a decent swimming pool and I am afraid that is not the case in every English town, is it? How has the debate about local authority responsibility for sporting provision been addressed in Europe for example compared with how we are addressing it here?
  (Mr Young) I do not have details to hand but I know that the statutory requirements on local authorities in various European countries varies. It is not the case that in every other EU Member State there is a statutory duty on local authorities to provide sporting facilities, whereas we do not have one. The more suppositive answer to your question is that the Sport England Lottery Fund is actually transforming the provision of sports facilities throughout the country. It just is. Since 1995 £1.2 billion spent and coupled with that the new Sport in Schools initiatives which we have and there is a transformation now of sporting activities, encouraged by local government and normally in partnership with local government. It is transforming itself.

  149. My final point is about sport in school. I was going to refer to the playing field issue but it has already been referred to. What work has been done on the amount of time that non-specialist PE staff commit to extra-curricular sport in schools? I am of the impression that, particularly in the 1980s as a result of some of the industrial action which took place in schools, staff no longer put themselves forward in such large numbers to help out with school teams and extra-curricular activities as they might have done previously.
  (Sir Michael Bichard) The statistics for primary schools certainly do not bear that out in that the time spent by children on after-school exercise and lunchtime exercise has increased over the last five years.

  150. Is that predominantly organised by staff whether or not they are PE staff?
  (Sir Michael Bichard) Yes.

  151. Do you have any information?
  (Sir Michael Bichard) No, I do not have a breakdown of which non-PE staff are involved in those sorts of activities. I very much doubt that we have it anywhere.

Mr Williams

  152. May I suggest to you gentlemen that you and we without waiting for our report learn one very valuable lesson this afternoon, which is that if we all take care of ourselves we too can look like Mr Steinberg? May I therefore suggest that you consider a national poster campaign with the Steinberg image scattered around the countryside as an encouragement to all those who lack motivation to take the advice you are giving? Coming to the basis of the report, and I am not saying this in the critical sense because effectively what we are faced with is the willpower and the decisions of every individual person in the country and it is actually rather difficult for a group of departments to predetermine the results they want. We are facing a situation where we know there are 30,000 deaths a year from obesity. The impression I got, which may be unjust, was that really you are all groping about a bit, trying to find solutions. I am wondering whether the correct questions are even being asked. There seems to be a lack of any coordination or a minimal amount of coordinated action. If we look at table 31, for example, on page 54, the thing which comes over in virtually all the diagrams we have except one is that the incidence of obesity amongst women is somewhat higher than amongst men, which I assume we split down to matters of metabolism rather than anything you or we can influence. If we look at the regional differences in obesity within England first of all, what is striking is that if you look at the spread of the statistics, as far as the prevalence of obesity in women is concerned the best is in South Thames with 18 per cent and the worst is in Trent with 24 per cent, one third difference. If you look at the men, the best amongst men is 14 per cent in North Thames and is 22 per cent in West Midlands, which is half as high again. What analysis have we done of these internal regional differences to see whether they give us any clues?
  (Mr Crisp) I am not sure that we will be doing analysis at that level of those regions. We have done analyses in health authorities, looking at what the particular issues are in localities. You can see that it is a multi-factorial issue, that some of it is to do with the population itself. This report indicates that there are some genetic issues here. There are some issues around lifestyle, which include the food which may be typically eaten or whatever and access to activity. I think we understand some of the determinants of why people are overweight and also we understand that we need to be much more systematic than we have been in doing things like providing advice to those people.

  153. That is all well and good. You have gone onto the general position of understanding the determinant of why people are overweight, but what you have not been able to do is explain the difference between the incidence of obesity. Having accepted that the causes may be somewhat similar, why is it that you have these incredibly wide disparities? If we look at the greater stability of large numbers, the regional figures are quite interesting. Has no work been done to try to understand the underlying causes of that?
  (Mr Crisp) I think there have. When you have something which is multi-factorial like this, what is important to understand, if you happen to be in Wales, or wherever it is, is what the local reasons are for why you have a significant problem in a particular area. Those will be a mix of a number of different issues. We need to understand it against a national norm.

  154. Yes, I understand that. We are back where I started that really you have no understanding of why the differences exist. You said there is a mix of factors but the mix differs from one area to another or between one health authority and another or between one region and another. If we are to try to isolate factors which may be influential, why is it for example that we cannot get the worst of these regions, say Trent in the case of women and West Midlands in the case of men, down to the level of the best? Is there no clue in there?
  (Mr Crisp) I am sure there is but it is still the same point that the reasons for obesity are to do with lifestyle, to do with diet and so on. If you have a particular problem in a particular area, those are the things you have to tackle. You need to tackle the diet more strongly for men in Trent than you do for men in North London.

  155. Yes, but what is the element in it which is different? You are still not answering the point.
  (Mr Crisp) The element in the diet?

  156. Yes.
  (Mr Crisp) I am not quite sure what you are trying to get at.

  157. It is all right to say that it is a matter of diet: we know that is an element. What is it which creates these wide regional disparities within the diet?
  (Mr Crisp) I am not sure that it is any one particular thing. If you want me to provide a more expert response to that, then I shall happily do so.

  158. If you can, please[15]. It is the same if we look at paragraph 2.7 and compare the experience of European countries where we are told that obesity increased between 10 to 40 per cent in the late 1980s to the late 1990s in the majority of European countries, but it doubled in England. There again, how do we explain the change in the incidence?

  (Mr Crisp) Maybe a more helpful point in what you are looking for is that England's obesity trend, talking specifically about England, is running precisely parallel to the USA's one, as opposed to running parallel to the West German one. That seems to me an indication that we have a more Americanised lifestyle than perhaps the Germans have.

  159. It is interesting because the Americans have a much higher living standard than we have and the Germans have a much higher living standard than we have. It is interesting that we are following the American pattern rather than the German.
  (Mr Crisp) We appear to be at this stage. I ought to go back to a point I made earlier, which is that the Germans started off at a higher level than we did in the first place. We happen to be paralleling the American one, whereas the German started higher and is still increasing. That is an indication of the importance of lifestyle and particularly dietary traces and so on.

15   Note: See Evidence, Appendix 3, page 27 (PAC 00-01/168). Back

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