COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Inquiry into Obesity
Department of Health, Social Services and Public Safety
18 June 2009
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Sam Gardiner
Mrs Claire McGill
Ms Sue Ramsey
Witnesses:
Dr Naresh Chada )
Ms Christine Jendoubi ) Department of Health, Social Services and Public Safety
Mr Rob Phipps )
The Chairperson (Mrs I Robinson):
This final evidence session of the inquiry is with officials from the Department of Health, Social Services and Public Safety. Members have been supplied with the Department’s submission to the inquiry and a briefing paper from the Assembly Research Services.
I welcome Mr Rob Phipps, Ms Christine Jendoubi and Dr Naresh Chada. I invite you to make a brief presentation, after which members may ask questions. We will allow up to one hour for the evidence session.
Mr Rob Phipps (Department of Health, Social Services and Public Safety):
We are pleased to be back at the inquiry’s conclusion. We have been following its progress with interest, and, through reading the Hansard reports, we have noted some of the comments and points raised.
When we first gave evidence to the Committee on 5 March 2009, Andrew Elliott outlined the Department’s position on the issue and stressed its commitment to addressing obesity across the life course. I wish to update the Committee on the work that has been, and is being, carried out on the issue of prevention. I will hand out copies of a newsletter to members; in fact, you are the first people to see it. It will be distributed to everyone who deals with the issue of obesity at local and regional levels and elsewhere.
At the last evidence session, we spoke about our intention to develop a 10-year strategic framework to address obesity across the life course. In our original submission, we annexed a logic model. The 10-year framework will be outcome-focused and outcome-based. It will take a thematic approach to the life course. For example, not only will it target young people, children, adults and older people but it will subdivide maternal matters into antenatal and post-natal issues. We can then consider other outcomes such as obesity in the workplace. The framework lends itself to a matrix-type approach, because it not only considers obesity in younger people or older people but it is also settings-based.
The short-term outcomes, which will probably take two to three years to achieve, have the potential to address many of the issues that have already been brought to the Committee’s attention, such as nutritional standards, levels of participation in physical activity by young people and older people, and the role and support of the food industry. All those issues can be covered within that outcome-focused approach.
Our steering group is cross-departmental, and the final framework must be cross-sectoral and cross-departmental. At present, four advisory groups are working on that to develop the outcomes, which they will complete by the end of September 2009. An email address has been provided in the newsletter for people to send in their thoughts and to make comments. Between October 2009 and January 2010, we will develop the framework. That will involve discussion and negotiation with other sectors and, in particular, the Departments. It is important that there is buy-in across the entire sector.
The big question is: how do we measure the success of those outcomes? How do we measure the difference that they are making and the impact that they are having? A data research group is currently working on that. It is examining the evaluation of good practice, as well as the types of surveillance systems that are in place.
Assessing progress and impact, and measuring the difference that is being made, is a big challenge. That will be built into the process, and we will have indicators that will demonstrate the difference that is being made. That is absolutely essential. A group is working on that, and we hope to finish that process by January 2010. People will feed their ideas and thoughts into the initial consultation, and it will then go out for full public consultation in February, March or April 2010. We will take on board the comments that we know we will receive, and we will then redraft the strategic framework. It sounds rather frightening, but we hope to launch the strategy by June 2010. That may seem a long way off, but there is much work involved to get it right.
That is where we are. I hope that the newsletter gives you more background to the process.
The Chairperson:
It is very helpful. Thank you very much.
Mrs O’Neill:
Early intervention is crucial, and the new Public Health Agency has a key role to play in tackling the epidemic. Do you see the agency having a role?
Mr Phipps:
The Public Health Agency is part of the process. The agency is represented on all the groups that I mentioned, including the steering group. It is already inputting to the development process, but it has an essential role in delivery and implementation. I am sure that members will appreciate that the agency is in the process of getting its structures in place, but we are keen to work closely with it, because it will be a key partner in the delivery of the framework.
Mrs O’Neill:
In relation to primary care, an incentive was introduced for GPs to identify patients over 16 years of age old who have a body mass index over a certain level. Does that not place more focus on treating obesity as opposed to adopting a more preventative approach? Is there an incentive to work with GPs so that they can help their patients to be more active or to refer them to use council leisure facilities, for example?
Ms Christine Jendoubi (Department of Health, Social Services and Public Safety):
It is opportunistic. We do not have anything in place for GPs to go out and hunt down fat patients. However, when such patients present, GPs are paid to offer them a resource pack that provides them with dietary advice as well as advice on smoking. However, one must remember that patients are free to turn down offers of treatment. GPs will refer patients to smoking cessation clinics, give them advice, carry out routine blood pressure monitoring and thyroid function tests. They will keep a register of obese patients and follow them up annually to measure their weight, test blood lipids and glucose. GPs will refer them to physical activity resources or programmes, but they are not universal.
I have read about practices in England that will prescribe patients a physical activity course in their local leisure centre. A GP can prescribe anything that a pharmacist can dispense, but, obviously, a pharmacist cannot dispense swimming lessons. However, it is entirely possible that arrangements can be made with leisure centres so that the cost of physical activity courses can be redeemed from the former Central Services Agency, or the Business Services Organisation, as it is now known. I do not know it for a fact, but I imagine that that is the general idea behind the Grove Wellbeing Centre, where the swimming pool is on site. That type of cross-governmental approach should be encouraged. That is the purpose of those types of dual amenities.
Mrs O’Neill:
Community planning will be vital, and that will provide the opportunity for the different agencies to get together to look after the population that they serve.
Mr Phipps:
In the early 1990s, the former Northern Board had a voucher scheme; GPs gave out vouchers to people whom they felt would benefit from them. Community planning will kick in in a couple of years’ time, and it will give a role to the agencies and the local councils. Local councils will be important, and leisure centres, in particular, will have a crucial role to play.
The Scottish weight-management programme Counterweight involves a patient’s GP and family. We are aware of those schemes; a representative from Counterweight made a presentation to the obesity prevention steering group. That programme is popular in Scotland. Further discussion is required for many of those issues, and there is potential to make suggestions.
The Chairperson:
Some councils do that already. Castlereagh Borough Council has a set-up in which people can use the leisure facilities to improve the quality of their health. As you say, local authorities will play an important role in the future with the redrawing of local government boundaries.
Mr Easton:
You are doing good work. I am not knocking you, but much of what you are doing, or what we are considering, is directed at people who already have a problem. Apart from the work that is being done in schools and exercise being recommended, what are you doing to try to ensure a healthier population? That is vital.
I keep harping on about the muck that food companies put into food. If that does not change, there will always be a problem, regardless of what we do; it will be akin to treating the problem with a sticking plaster. Are all our food laws governed by Europe? Is that our major problem? Are you examining legislation that we could use to try to force food companies to moderate the doses of various ingredients that they use?
There are four advisory groups examining four issues. Why do you need four groups? Is it merely to speed up the process?
Dr Naresh Chada (Department of Health, Social Services and Public Safety):
I agree that it is vital that we target people in the early years, and all the public health evidence bears that out. The structure of what we have been trying to do in Northern Ireland through Fit Futures and the further work that Rob Phipps outlined tend to corroborate that line of thinking.
None of us is an expert on food legislation, so I am happy to get back to you on some of the details. I understand that the Food Standards Agency gave evidence to the Committee and informed you that most of the legislative issues relating to food and, particularly its content, are set by Europe and, to some extent, national legislation. Therefore, we are constrained about what we can do in Northern Ireland.
Mr Phipps:
There will always be an issue about food and nutrition. Dieticians and nutritionists always have issues about food and nutrition. Similarly, representatives from Sport NI and other colleagues will say that physical activity is also important. We acknowledge that, and we thought that the best way to ensure that we included that in the framework was to have experts from those two groups to raise those points. Mr Easton’s points may be discussed at the food and nutrition group, for instance.
There is also an issue about consistent messages. Inconsistent or different messages going out at the same time, or at different times, annoy everyone. The education, prevention and public information advisory group is tasked with trying to achieve consistency. A point was made about the role of the Public Health Agency, public health campaigns and public campaigns. It is imperative to achieve consistency, and that advisory group has been tasked with that.
The fourth group is concerned with data and research, which involves a roomful of researchers and statisticians who grapple with the big issue. The newsletter may state that. We also bring the chairpersons together. They are not independent to the extent to which they plough their own furrow, so we bring them together and have regular meetings, which is when the crossover occurs. That works well.
Mr Gardiner:
I ask for clarification because my mind is probably not functioning properly. The newsletter states that, in Northern Ireland, some 59% of adults have a weight problem, and 5% of children in primary 1 are obese, with 22% of children in primary 1 being overweight or obese. Does that mean that 17% of children are overweight?
Mr Phipps:
Yes, it does
Mr Gardiner:
That is not very clear.
Mr Phipps:
Thank you very much. The newsletter has not yet been circulated, so we can make that clearer.
Mr Gardiner:
Please do that because you are contradicting yourselves somewhat.
Mr Buchanan:
I welcome you to today’s meeting. I commend you for the ongoing work. This is a big issue that has come to the fore in Northern Ireland in recent years. Early-years intervention is vital. It is important to educate in the early years because prevention is always the best medicine. I assume that some of those groups work with schools, the education system and local authorities to establish incentives so that people are encouraged to try to tackle this serious problem. What plans are in place to treat overweight children and adults in the secondary sector?
Ms Jendoubi:
If they are older than 16 years of age, they will fall within the ambit of directed enhanced services (DES). There is always an opportunity for the surgical route, but we do not recommend that because people do not routinely go down that route. Many teenagers, particularly girls, want that route, which they see as being the easy way out. However, it is not a route that we routinely recommend because it is drastic.
There are also normal dietetic services from the trusts. Youngsters will be referred when they present. If they go to their doctor with a problem, or if they turn up with any kind of health problem and their doctor feels that they have a weight issue, they will be offered a resource kit if they are old enough to avail themselves of it. They will be offered routine tests, and they will be followed up for weight measurement and routine monitoring as quickly as the doctor feels that they need to be. They will then be referred to a trust dietician for further advice.
Mrs O’Neill:
Are allied health professionals represented on the obesity prevention steering group?
Mr Phipps:
I would need to double-check that.
Mrs O’Neill:
A witness in Committee told us that allied health professionals were not involved, and they felt that they were not represented. They would have much to offer.
Mr Phipps:
Bear with me; I have the membership of the steering group, but I will have to go through my 3,000 documents. People say that various groups should be represented, and we say that that is great. We are inviting people. Just now, I cannot see a representative. However, I will take that point and ensure that there is an allied health professional by the next meeting.
Dr Deeny:
I am sorry that I was delayed.
On the subject of exercise, I have worked in general practice for years now, and it is important to promote exercise. It is not only good for physical health and the prevention and tackling of obesity but for mental health. Some years ago, a couple from England who came into my area suffered a terrible tragedy and lost a family member through suicide. That couple has come on in leaps and bounds because they exercise frequently at the leisure centre. Their intake of drugs has gone down dramatically. I see that every day.
In 2010, the cost of prescriptions will be reduced to zero. However, should it not be the case that, across Northern Ireland, GPs should pick appropriate motivated patients for exercise programmes? Motivation must be assessed for all types of conditions.
Last week, representatives of the Department of Education were witnesses at the Committee. They told us that they would consider the Department’s guidance of two hours’ physical exercise for schools. I do not think that that is enough. Physical exercise should be compulsory, and it should be almost four hours a week. I suspect that some schools do not do physical exercise at all, and the focus is far too much on academic activity as opposed to exercise. For want of a better phrase, we are getting some obese Einsteins — children who are bright but not physically fit. Will the Department of Health, Social Services and Public Safety work with the Department of Education on that matter?
With the advent of the new local commissioning groups (LCGs) — I must declare an interest because I am a member of the Western Local Commissioning Group — will GPs and elected councillors work together on commissioning groups and perhaps come up with exercise programmes to improve public health?
Mr Phipps:
The process that I described means that people can suggest such outcomes for the role of GPs and that of physical education in schools. Our physical activity group met yesterday, and the Department of Education was represented on it. They spoke about giving evidence to the Committee last week, so the number of hours of physical activity was a discussion point. We are keen to work on that area.
I take the point about linkage with good mental health. One of my personal frustrations is that much of our work is about promoting self-esteem and good body image, which is excellent for mental health. It cuts across a range of lifestyle behaviours — alcohol, drugs and other issues. We are aware of those points. There is a potential for those to be built into the strategic framework, but we will then have to get the buy-in. There is certainly potential, and we are working closely with the Department of Education and the Department of Culture, Arts and Leisure on Fit Futures.
Dr Chada:
The point about local commissioning groups is extremely important. When the public health infrastructure matures at a local level, it will be important for local commissioning groups to work with partners such as local government and public health professionals. That will ensure a common approach so that people have access to exercise and leisure opportunities, thereby tackling the obesity issue. We need to examine that work carefully at a local level. Commissioners need to take that on board.
Mr Phipps:
It is a challenge; it is part of the regional vision, but it will be delivered locally. The framework will, I hope, enable that so that there is regional consistency. However, local bodies know their localities better than we do. The entire process is about that, and it can put in place those types of initiative. There must be consistency in what we are saying. One can go to area A and receive a certain message, and then go to area B and receive an entirely different message. People might say that we should get our act together. However, it is about how the issue of messages and information is managed. It is not unique to health issues. There is a range of issues, and it is about trying to manage a regional vision against local delivery.
Dr Chada:
What might be appropriate in an inner city might be completely different in a rural setting. We must consider all the initiatives to see how they can best be evaluated and in which setting they will be the most effective.
Ms Jendoubi:
We would expect local commissioning groups to turn their attention to that issue, and the fact that councillors and doctors are on local commissioning groups should make life much easier.
When Barry Gardiner was Minister with responsibility for education, he had plans to increase the length of the school day and have two hours’ physical activity in the middle of each day. However, that did not go down terribly well with the teachers’ unions, and the plan was not pursued.
The Chairperson:
That concludes the oral evidence for the inquiry.