Examination of Witnesses (Questions 40-59)
12 JUNE 2003
MR MIKE
ASH, MS
DANILA ARMSTRONG,
MS IMOGEN
SHARP, MS
PATRICIA HAYES,
MR ALEC
MCGIVAN
AND MS
MELA WATTS
Q40 Dr Naysmith: We are going to
embark now on a series of questions about to what extent the National
Health Service and the department take this subject of obesity
seriously. You have already heard this morning that it can be
quite difficult with a cross-cutting issue like that to get departments
to meet and talk about things and devise a common strategy. But
even with the Department of Health there are different subject
departments and sections. I wonder if you think it is the case
that it is taken seriously enough by the Department of Health.
Ms Sharp: I think, in terms of
the Department of Health, yes, ministers certainly do take this
issue seriously. It is something that the Public Health Minister
in particular is concerned about and has stated publicly her concerns
about rising levels of obesity—which, I would stress, are
not just in this country but are a global phenomenon and a global
epidemic. I think we recognise, therefore, that it is not an easy
problem to tackle, but it is certainly one that has health consequences
and NHS cost consequences. So, yes, it is taken seriously. I think
it would be fair to say that our work internally comprises of,
I suppose, two strands. One is the prevention, beginning in childhood
and focusing on diet and physical activity, which obviously is
a cross-government activity but, certainly from the Department
of Health's point of view, I suppose, the first focus on that
has been on diet, with the national 5 A DAY Programme, the National
Fruit Scheme and a range of initiatives there. In terms of exercise,
now we are doing a similar approach to that. We have recently
set up nine link pilots which follow the same sort of model as
the 5 A DAY local community initiatives programme, where they
are evaluating work by primary care trusts and giving money to
them. In terms of the NHS, yes, I think it is increasingly taking
it seriously and we have put in place a series of structures,
including a new Priorities and Planning Framework, which has a
target for registers, which guides them. They have to deliver
priorities in the next three years.
Q41 Dr Naysmith: I am glad you mentioned
primary care trusts. That is the area I want to ask you about
specifically doing something about this. Implementing, for instance,
the National Service Framework on Coronary Heart Disease, one
aspect which would seem to be useful would be looking at body
mass index and monitoring it and controlling it and seeing to
what extent it was happening in a particular area and with a series
of patients. How do you know whether that is happening or not
with primary care trusts?
Ms Armstrong: It is obviously
the responsibility of primary care trusts to set their own local
priorities in partnership with other commissioners and also to
look at how they are going to be monitoring that. As Ms Sharp
has already mentioned, there is the requirement of primary care
to set up diabetic and CHD registers and on those registers there
will be a recording of things like body mass index.
Q42 Dr Naysmith: How is this monitored
back at headquarters? I know we are trying to get them to move
things away but, if you are setting this up on a National Service
Framework, you have to make sure this is happening.
Ms Armstrong: The responsibility
for the performance management of primary care trusts rests with
strategic health authorities. Strategic health authorities are
accountable to the Department of Health in delivering local delivery
plans and also in delivering the local delivery plans returns,
and in delivering obviously the priorities and planning targets
as set out for 2003 to 2006. In addition to that, there is also
CHI (Commission for Health Improvement) who are undertaking a
review particularly of the NSF for coronary heart disease. It
is an implementation at local level. That process is starting
now and will be reporting on how that is being taken forward at
the local level.
Q43 Dr Naysmith: So you do not have
any figures for us yet. It is too early.
Ms Armstrong: We do not have any
figures.
Q44 Dr Naysmith: You do not know
what proportion of primary care trusts are implementing this.
Ms Armstrong: Implementing in
terms of recording BMI, no, we do not have that information at
the moment, but, following the Commission for Health Improvement
review, we will be better informed what proportion of primary
care in PCTs are actually gathering that kind of information and
how effective they are in implementing NSF for CHD.
Q45 John Austin: You have said the
responsibility rests with the PCTs. If we go back to the White
Paper The Health of the Nation, that did identify targets
for obesity reduction. They were not present in the public health
White Paper Saving Lives. Does that send the right message
to PCTs about the importance the Government attaches to tackling
obesity?
Ms Sharp: As you acknowledge,
I think that is a question for ministers, but the ministers chose
to reduce the number of targets. They had concerns about the amount
of targets that were being set and very deliberately focused on
outcome targets of heart disease, cancer and an inequalities target,
which is also reflected in the local planning at the Priorities
and Planning Framework, so they took that decision. However, that
does not stop us monitoring trends and having indicators of progress
towards those, and obviously we recognise that obesity, diet,
exercise all contribute to the heart disease target as well as
smoking and other things and are monitoring that through indicators
at a national level.
Q46 John Austin: Also not just heart
disease but also cancer rates as well.
Ms Sharp: Yes.
Q47 John Austin: You have said it
is the PCTs' and then it is the strategic health authorities'
responsibility to monitor that. Doug Naysmith asked a specific
question about the Coronary Heart Disease Framework. Do you have
any idea of how many PCTs actually have an identified lead member
for obesity issues?
Ms Armstrong: I do not have the
answer to that question. We know that in each of the strategic
health authorities there will be lead people who have responsibility
for coronary heart disease.
Q48 John Austin: Will there be an
expectation that each PCT would have a strategy?
Ms Armstrong: There is an expectation
that each PCT will have a local delivery plan which then feeds
into the strategic health authority's local delivery plan which
then is the one that gets reported back to the Department of Health.
Q49 John Austin: If we want to know
how many PCTs have a strategic plan and a lead person, we would
need to ask one of the SHA.
Ms Armstrong: At the moment, yes,
that is correct.
Q50 Dr Taylor: I am going to ask
the Department of Health some more rather awkward questions which,
if it cannot answer, I think we ought to have—just as I
think we ought to have the answer to the question how many PCTs
do have a lead officer for obesity. NICE Guidelines, which are
pretty well the law these days, when they are talking about the
drugs for obesity, do say "arrangements should exist for
primary care staff, mostly practice nurses, supported by community
dieticians, to offer specific advice, support and counselling
on diet, physical activity and behavioural strategies." You
probably do not know but could we find out how many PCTs do have
practice nurses who are actually trained in this sort of advice?
How many have access to community dieticians who again are trained
in this sort of work. Could you give us a rough idea of the training
GPs actually get these days in handling obesity. That is something
you might be able to answer now, I do not know.
Ms Sharp: If I take your first
point about how many of us are doing that in how many PCTs, I
would say that is something that we are actively looking at at
the moment. It is something about which I have some concern. In
the context of this three years' plan, we have identified the
need for workforce development as being a priority over those
three years. There we are working with the workforce development
confederations, etc. We are essentially doing some work around
that which will involve, we have agreed, some form of survey or
something to find out levels of understanding and knowledge, etc,
and therefore what training guidance might be needed.
Q51 Dr Taylor: It would be very helpful
if we could have some sort of rough idea of the numbers of PCTs
that do have these sort of people available to them. That is impossible,
is it?
Ms Sharp: I think we would need
to look at, I suppose, the burden that that would give. We are
intending to do some analysis or some survey of exactly that area.
Q52 Dr Taylor: Is it not something
strategic health authorities should have at their fingertips?
Ms Sharp: Yes.
Q53 Dr Taylor: It should not, to
me, require that amount of work.
Ms Sharp: But it is something
that we can undertake to ask the directors of public health and
the strategic health authorities, if that would be helpful.
Dr Taylor: I think it would.
Q54 Sandra Gidley: As an add on to
that, does the department have any idea how many doctors surgeries
are offering exercise on prescription as an incentive?
Ms Sharp: The department's position
on that is we have produced the guidance on the Quality Assurance
Framework for Exercise Referral. We also have an understanding
that there are about 500 but, no, we have not collected that data.
We, I suppose, keep an informal check on it but we have not undertaken
to collect—
Q55 Sandra Gidley: That is 500 out
of . . . Can you turn that into a percentage?
Ms Sharp: May I come back on that?
Q56 Chairman: You can come back to
us with the answer.
Ms Sharp: Okay. Could we come
back to you on that? Thank you.
Q57 Julia Drown: You talked there
about workforce development. Are there any thoughts about whether
there needs to be some new type of worker in this field, somebody
who knows about family counselling, about diet and physical activity?
Is there any work being done on that?
Ms Sharp: The things we have in
place, particularly in terms of workforce development. The Health
Development Agency, the remit of which is specifically to review
the evidence and also to do guidance and practice development,
is due to be publishing fairly shortly guidance on obesity. There
is also—
Q58 Julia Drown: That would not be
about a new type of staff.
Ms Sharp: No, that is about evidence
of effectiveness. They are also setting up a number of collaboratives,
in terms of workforce development and working with the workforce
development confederations and others, about what would be needed.
I think this would need to be considered in the case of that.
Ms Armstrong: There are also various
programmes in place. For example, there are life skill escalator
courses for enabling people who perhaps are not necessarily professionally
qualified but can get some sort of supervision to deliver some
of this work, particularly out in the community. For example,
in the case of dieticians I am aware that there are schemes in
place to take this sort of broader approach.
Q59 Julia Drown: So we might be seeing
these roles emerging.
Ms Armstrong: Yes. Because of
the limit on the number of our specialist staffs that can deliver
this work.
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