Examination of Witnesses (Questions 140
MONDAY 23 APRIL 2001
BICHARD, KCB, MR
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 timeand it was published last week
or the week beforeguidelines 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
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
(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
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.
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?
(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.
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