Examination of Witnesses (Questions 520-539)
6 NOVEMBER 2003
DR ALAN
MARYON DAVIS,
MR JOHN
GRIMSHAW, PROFESSOR
CHRIS RIDDOCH,
DR SUE
CAMPBELL CBE AND
MR TOM
FRANKLIN
Q520 John Austin: Dr Maryon Davis
mentioned the issue of availability of facilities and cost. One
of the areas where the UK is sadly deficient compared with many
of its European neighbours is in swimming facilities. It seems
to me that swimming has virtually disappeared off the school curriculum
at this stage. Is there any evidence to back that up?
Dr Campbell: I am sure there is
evidence that there is less swimming. The Department for Education
and Skills is just about to produce a charter to try to re-engage
schools more in swimming. One of the problems is that if there
is no pool on the school site, you are talking about cost of transport,
which starts to become a barrier, you are talking about time.
Q521 John Austin: They could walk.
Dr Campbell: It is true that they
could walk, but that is even more time.
Q522 John Austin: Or cycle.
Dr Campbell: It is not safe. You
then have the whole business of one person going and changing
30 little people into swimming costumes and trying to dry them
all off and change them and get them all back again. It is pretty
time consuming. What we have been looking at, particularly for
primary schools, is that actually the best way to learn to swim
is in a more compacted space than once a week for a series of
weeks. What we tried was what we called a top-up course this year
where we actually took all the youngsters who could not swim in
a whole geographic area of primary schools and gave them a three-day
course in swimming to ensure that at least they could swim. We
also did it and introduced all the other different kinds of fun
you can have. Actually you can deliver the whole national curriculum
in the water if you want to. You can do games, play polo, you
can do esthetic activity, synchronised swimming, you can do endurance
work and athletic work because you can swim up and down. You can
do an awful lot in the pool to deliver physical education. What
we have found from that is that we are now tracking those youngsters
to see whether they are returning and going swimming on a regular
basis. It drops off quite quickly, as I think you will find if
you look at the Welsh study. Wales opened all their swimming pools
to young people this summer all free of charge and got a tremendous
response. As soon as you charge again the thing starts to dive
again. Cost is an issue, transport is an issue, time is an issue.
I agree with you that swimming is a tremendous activity whether
you are young or old. It is something I try to do.
Q523 Mr Burstow: In our trip to the
States we learned that in New York the pools are free during the
summer as well and that was quite interesting. I just want to
pick up Professor Riddoch's point about what to measure and the
assertion he made about much preferring to measure physical activity
than weight. One of the things we picked up during our visit to
the States was how obesity is rapidly becoming the number one
behavioural cause of death in the United States and how it is
the gateway disease through which a whole range of other diseases
are triggered and risk factors are increased. Are you really saying
that we should not have any focus at all on the issue of weight
gain? Do you really think that just focusing on activity, which
is understandable today in terms of the evidence you are here
to give us, is going to address the obesity question?
Professor Riddoch: It is more
a question of where the measurements are made and the chances
of stigmatising children and humiliating them in front of their
peers and all that sort of thing. The physical education department
or the school is the place to measure physical activity. The place
to measure weight is maybe with the general practitioner or the
school nurse or something like that. It is a different issue,
a sensitive issue. It is not a screen for physical activity. It
obviously involves diet as well.
Q524 Mr Burstow: Do you really think
that it is a sensible thing to do, to separate out the issues
around activity and getting good PE teachers who can really motivate
and encourage people, all that, when they do not necessarily have
the knowledge around the diet issues? Surely those two have to
be part of one package. Are they already clearly addressed in
that way in the curriculum? Could more be done on that?
Professor Riddoch: There is certainly
a move in public health generally towards more multi-skilled health
professionals who are skilled in diet and exercise and maybe smoking
cessation as well. If that could be reflected in the education
of teachers, that would be a great move forward.
Dr Campbell: Secondary physical
education teachers do study health related exercise, particularly
if they are doing GCSE PE or A-level PE. There is a real underpinning
of helping youngsters understand and have a much broader understanding
of health based issues. We could do better and we need to do better
in the future. The area where we perhaps do less well on that
is the primary level because of the limited training time we have.
They tend quite naturally to be more concerned with delivering
safe activity than educating through that activity, because that
is as much as their training has allowed. Your question is a very
useful one and it is something on which, both at primary and secondary
level, we could put greater emphasis and have greater benefit.
Many young people, when they are asked whether they like PE answer
no. The next question I always ask is: did you understand the
relevance of doing it? Answer: no. We have not helped them understand
the very basic issue of why it is important to be physically active.
You are right, that needs to get built in and we need to do a
better job at bringing that much more to the front of our teaching
rather than letting it get hidden at the back of our teaching
sometimes.
Dr Maryon Davis: I just want to
get away from schools at the moment. You were talking about obesity
emerging as the number one contributor to early mortality in the
States and we probably following here in about ten years' time.
In primary care, which is another important setting for this sort
of work, smoking cessation is well funded, it is beginning to
be reasonably well co-ordinated: we have a three-tier system of
basic advice given by the practitioners, an intermediate level
which is done on a group basis locally and then a specialist level
where you are referred to a specialist unit. What the Faculty
would like to see is a similar sort of setup for dietetic advice,
in terms of getting brief advice from the practitioner nurse,
referral to a community dietician for further advice and then
referral to a specialist service. The same around exercise too:
some brief motivational advice from the practice nurse or GP,
referral to more specialist advice and then, for those who really
need it, something much more tailored to them. We do not have
that. We do not have that infrastructure. We do not have the resources
for that. It is not something which is well organised at local
level. We believe that those should be firmly established services.
As well as a smoking cessation service, we have a dietetic service
which focuses on obesity amongst other things, diabetes and other
thing and an exercise service as well, well organised and well
resourced.
Q525 Mr Burstow: One of the things
we have seen in evidence is this whole issue of GPs making exercise
referrals. We understand also that the health education authority
have done some evaluation of that in the past back in 1998, but
they have said that there is an even much more rigorous evaluation
of these sorts of things, because there are not actually very
many of them around the country. Are you aware of any pieces of
work which have been done which would give sound reliable information
to judge whether or not these packages work and which ones work
most effectively?
Professor Riddoch: I actually
wrote the report you referred to. It is very difficult to measure.
That is a common scientific answer, but it is. You are trying
to measure complex behaviour out there in the field, not in a
laboratory. There is a large trial in north London which is reporting
very soon, the first well-funded study involving multiple GP practices
and that will give us the first real handle on how effective these
schemes were. The point I should like to make on all of this is
that we have had a very succinct summary of what is going on with
children here. Alan has mentioned primary care, it is very easy
to look for a magic bullet about how to get population levels
of activity up and there is not one. We have to do what Sue says,
we have to do what Alan says, we have to change the built environment.
Unless we get everything working in concert, then the population
levels of activity are not going to shift very much.
Q526 Mr Burstow: What sort of timescales
is that evaluation work you have mentioned working to? When is
it likely to be published?
Professor Riddoch: I know there
is going to be a presentation of the results, which I believe
will be the first presentation at a conference, and I think it
is in April next year.
Mr Franklin: We have to be slightly
careful about this push towards referring people to exercise,
to gyms and so on. While that works for some people, it does not
work for the vast majority of people. It is like the Bridget Jones
syndrome of joining a gym and then working out it has cost you
£150 every time you have gone because you have been twice
in the year. Joining is one thing: actually going is another thing.
I have certainly joined somewhere and then there have been three
or four months when I have not been and then you eventually get
round to cancelling the subscription and everything else. For
the people who probably need it most, they are the ones who are
probably least likely to make the big changes to their lifestyle
that they need in order to get the benefit from the gym. It is
much more about building in through GPs, through primary care,
how we can motivate people to make these very small changes. It
is not big changes, but it is very small and it then has to be
consistent, making those changes over every day of their life.
It might be simply walking to the bus stop rather than taking
the car. This sort of thing. We have to look inclusively and I
am just a bit worried that we focus too much on physical activity.
Q527 Mr Jones: In the last few contributions
I am recognising what I often see when in meetings like this,
that people look at things according to ensuring their own professional
organisations, their own gatekeeper roles. Naturally people who
are involved in sport will wish to enhance their professions,
but at the same time, ensure their professions have a clear role.
We do not want it muddied with ideas of healthcare. Those health
professionals very much want to ensure that they safeguard their
role as gatekeepers. Sometimes, in fact quite often, those desires
from professional organisations to ensure that they protect their
organisation and the meaning of their organisation gets in the
way of delivery. I think it might be getting in the way of delivery
here.
Dr Campbell: If any of us here
are giving the impression of gatekeeping, it is not the one we
intend.
Q528 Mr Jones: May I just make it
clear? The practicalities of referring everybody for quite simple
health messages to primary care, to GPs, when you look at how
overwhelmed GPs are, in my view is not the best way of sending
simple messages to a large number of people.
Dr Campbell: It is part of it.
Dr Maryon Davis: You have to see
it as part of the whole palate. Rather than thinking of it in
terms of professions, I would think of it in terms of setting.
We are looking at the setting of the home or the family, the individual
setting of the school, the setting of the workplace. We have not
talked much about the workplace which is an important setting.
We are looking at community groups and what we can do through
community groups. Primary care is a setting. I raised it because
it is important for some people for whom basically it is a particular
risk. I am thinking of people who have a family history of heart
disease, of diabetes, of high blood pressure, osteoporosis, a
whole range of things. Those are the people for whom we do have
to use what you might call the high risk approach, focusing on
those people who have particular risks and making sure we have
a service for them.
Q529 Mr Jones: In your earlier evidence
you told us that the generality of people are getting fatter.
We know that is happening, and we know that we have schools which
are wonderful institutions and we have everyone together. We have
them and we can do things. If you are going to say this is the
only way you can do it—
Dr Maryon Davis: No, I did not
say that. It is not either/or.
Q530 Mr Jones: But Sue Campbell said
she did not want to be looking at feet because it was not a pleasant
job. She wanted to be enhancing sport, because that was what she
trained for.
Dr Campbell: I do not remember
saying that. Did I say that?
Q531 Mr Jones: Yes, you did.
Dr Campbell: I did say I do not
like looking at feet. I do not remember the second phrase.
Dr Maryon Davis: Many years ago
Professor Geoffrey Rose formulated a model that you need two complementary
and mixed approaches. You need a whole population approach, which
is the very wide, "let's get everybody up to speed"
approach. However, you need to complement that with a focused
high risk approach for those individuals at particular risk. The
two are together. They are not mutually exclusive. Whatever formulation
we come up with, recommendations we come up with, we should bear
in mind that there is that spectrum.
Q532 Chairman: Jon wants to shift
us in a slightly different direction, but before he does and he
leaves schools, may I ask one question of Sue Campbell? You were
talking about how you could do many parts of the curriculum in
a swimming pool. That reminded me of when we were in the States.
I think it was in Colorado where they have a lot of good ideas
on exercise. They made the point that the use of the pedometer
in a classroom setting was quite helpful. What they were doing
was collectively measuring how far the youngsters had walked,
say in a week. Then they looked at this total amount for a class
on a map to see how far they had walked from Denver or wherever.
Then they focused their class session, whatever subject matter
it was, on that area. It might have been some mathematical problem,
geography, or whatever the subject was and they located it in
respect of the exercise they had taken. We did a quick Round Robin
this morning before the Committee had started and I worked out
that collectively in the past week as a Committee we have walked
to Yorkshire in total. I am not sure where that takes me, but
I just thought I would make that point. Have you come across any
imaginative sorts of connections between the exercise issue and
the way that can be used within the school setting?
Dr Campbell: Yes, we have quite
a lot. If it would be helpful, I can send you a summary of some
of the cases.
Q533 Chairman: It would be very helpful.
Dr Campbell: It is the kind of
thing the specialist sports colleges have been very much focused
on. Some of them have taken health as very much their kind of
theme. We have some excellent examples.
Q534 Chairman: If you would do that.
Dr Campbell: Yes, I shall do that.
Q535 Dr Naysmith: I want to move
on to a different area to do with the commercial involvement in
generating obesity and so on. It ties in quite nicely with something
Dr Campbell was saying about enabling children to make informed
choices. What are your views on commercial tie-ins between companies
like Cadbury/Schweppes and Walkers Crisps in providing recreation
facilities or computers for schools in return for tokens or labels
off the products they make, which tend to be harmful, certainly
if taken in excess? How do you think we can approach that area?
Dr Campbell: I am probably going
to be the one out of sync here with everybody else on the top
table. First of all I would say that Professor Clive Williams,
who is an eminent sports nutritionist based at Loughborough University,
has an expression which says there are no bad foods, just bad
diet. What we have to be careful about in our desire to safeguard
our young people is not to remove them from the real world in
which they live. The power of some of these brands, which we may
choose to keep away from young people, to communicate and to present
a message in a way which people in the public sector, or even
well-meaning people in the charitable sector that I represent,
cannot communicate effectively with those young people, is a really
tough one. I personally believe that if we vilify them and exclude
them from the opportunity to work with us, we are in danger of
assuming that children do not make informed choice, or are not
encouraged to make informed choice. Secondly, we are losing the
opportunity to reach in a very distinctive and different way,
which some people may not agree with, but a distinctive way, reaching
those youngsters who perhaps our public service type message does
not reach. Certainly, why can we not work with a company like
Cadbury, which in a given period of two months will put 120 million
messages into the marketplace, to engage in a positive dialogue
which helps them become part of the solution rather than part
of the problem? I feel quite strongly.
Q536 Dr Naysmith: That is not really
the question. I will come to that in a minute and the ways companies
can work. Is it a good thing for us to encourage companies to
come into schools in that kind of backdoor fashion when they seem
to be helping, but what they are actually doing is promoting their
products.
Dr Campbell: The Youth Sport Trust
has done a lot of work with a whole range of companies and the
answer to that question is that there are some companies which
do not do this with any degree of integrity at all and I would
agree, we should not be anywhere near them. There are some companies
which genuinely enter into a debate. Yes, of course, we are not
stupid, they are commercial companies, but they genuinely enter
into the debate and want to be engaged and be part of the solution.
They accept their responsibility for the part they play and want
to be part of the solution. If they are entering with integrity,
entering with the right motivation, then my answer, which is probably
not the popular answer, is yes, I would work with them.
Q537 Dr Naysmith: This is straying
into what I was going to follow up with in asking how companies
can help. Some of these fast food companies, confectionery businesses
are anxious to assure us that they want to be part of the solution,
as you have just laid out. Certainly, when we met Coca-Cola in
the States, they said that to us. They said that they wanted to
work with health providers and governments and local authorities
to try to reduce obesity, but their answer to it, unfortunately,
when we were talking at the time about slot machines in schools
delivering soft drinks, was that they had to give people a choice.
They had to make sure there was something else in there besides
Coca-Cola. I did not really think that was an answer.
Dr Campbell: No. Vending machines
in schools is a separate issue and if that is the motivation for
their involvement, which is to get more vending machines in schools,
I would say that lacks enormous integrity.
Q538 Dr Naysmith: It happens in this
country too now.
Dr Campbell: Vending machines?
Q539 Dr Naysmith: Yes.
Dr Campbell: It does indeed; absolutely
it does. Those are choices that head teachers make and I think
that is an interesting choice they make. A lot of pressure is
being brought to bear on them and they are beginning to make different
choices about what kind of vending machines, what kind of diet
we are putting in front of youngsters. It is a fine line between
whether or not you can work effectively with these companies in
a managed way or whether you just take a blanket approach and
say this is something we are not going to do. If I take one which
is less emotive, because it is not about food, if I take Nike
as an example, the work Nike has done on zone parks in primary
schools has come directly from their course related project budget.
They have no particular desire—I do not think, although
you would probably tell me they do—to sell kit to primary
age youngsters, although I presume they get brand affiliation.
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