Examination of Witnesses (Questions 1300-1319)
11 MARCH 2004
MS MELANIE
JOHNSON MP, MS
IMOGEN SHARP,
MS DANILA
ARMSTRONG AND
DR ADRIENNE
CULLUM
Q1300 Chairman: We have had it put to
us by a number of witnesses that your government and the previous
government have been rather slow to act on a very obvious Public
Health problem of quite serious dimensions. The figure that presumably
the Government had when it came into power in 1997 was that in
1980 8% of women and 6% of men were obese; that is the official
figure that was available at the time. By 1998 it was 21% of women
and 17% of men. That must, in 1997, have given some pretty alarming
messages to the incoming government, but the picture that we have
since 1997 on the obesity issue in particular from a number of
witnesses has been that we have not addressed it with the urgency
that we ought to have done. In fact, I got the impression in the
first Parliament of the labour Government that Public Health was
suddenly coming back into the mainstream but for whatever reason
I gained the impression—and I think possibly one or two
ministers give the impression now -that we perhaps lost it slightly.
I wonder, in the context of obesity, what your views are on why
the Public Health went on the back burner earlier in this Parliament
and we are now suddenly having to address what is a very serious
problem with quite frightening implications.
Miss Johnson: I would not agree
with your basic analysis. I think fundamentally there has not
been the focus pre-1997 on Public Health that you might have expected
in general.
Q1301 Chairman: I agree with that, but
what I am trying to say is that in the first Parliament we set
out an agenda which was quite radical in some respects and very
refreshing and some very positive messages were going out. However,
for whatever reason—perhaps involvement with a kind of side
show of things like foundation hospitals—we lost the policy
focus and I find that very worrying in the context of the alarming
figures of worsening health that we have, clearly with the figures
on obesity.
Miss Johnson: I understand what
you were saying originally and thank you for the clarification
of it. I think what I would say is that we originally had a very
strong springboard for all this; having a Minister for Public
Health was an innovation in itself. We had a Public Health White
Paper which I know you are recognising in your remarks, but taking
that forward I think one would expect there to be time to focus
on actually making some of the achievements that are necessary
(for example, on the smoking front, the advertising ban and all
the rest of it which we have carried through). There were many
things there that were actually being focussed on very strongly.
Your question is about obesity and I think in relation to that
that many Public Health people have acknowledged that the problem
has crept up quite quickly and quite surprisingly. Many of them
have gone on the record on national media as saying so, so I think
epidemiologically people were surprised at the speed and the incline
of the growth in obesity. I think it has caught us all slightly
unawares and I think we can see from the last year or so of interest
in it, both amongst the public and the media and, obviously, with
the strong focus that is going on in the House and in the Department,
that actually that has been picked up pretty rapidly by all parties
concerned to reflect that and to take the issues forward that
are coming out of it.
Q1302 Chairman: One of the concerns expressed
to us is the suggestion that the Government has not acted as rapidly
as it might have done. The Food and Health Action Plan was first
announced in 2002 but as yet has not been published. The Chief
Medical Officer was, I understand, due to publish a report on
Health and Activity last autumn which we still have not seen.
The impression is that perhaps if there is an awareness of these
very worrying trends, we have still not acted with the urgency
that might have been expected.
Miss Johnson: I think that the
truth of the matter is that in many of these areas the analysis
is now well-known to many of us. Certainly the importance of the
issue, the rough scale of the issue, many of the many contributory
factors are known and understood and agreed by many. I think the
main issue now is what we do to address those questions, and I
think that opens up a very broad front which is why not only do
we welcome that Wanless has done, but we welcome also the has
gone on in contributing to the Food and Health Action Plan and
the ACT's work on physical activity. Those plans will be out for
consultation as part of the White Paper process after Easter,
so they will feed into the White Paper and will actually be brought
together in that single context which will obviously look more
widely than simply obesity, but obesity is a key issue within
that White Paper proposal.
Q1303 Chairman: You have a very wide
ranging brief. You will be before us again soon on palliative
care. Within your brief what priority does obesity occupy?
Miss Johnson: Obesity has a very
high priority because it is a significant contributor on the cancer
statistics and the real need we have to cut cancer rates in the
UK; it has a major contributory factor to coronary heart disease
and diabetes where we also have very big problems and where we
need to cut the scale of the problem. We do not need just to slow
the growth; we need to reverse the trend. What we are looking
at is something which is a major core element of not only a lot
of mainstream preventative work but also a lot of the management
of disease and the focus of the work within the NHS as well. It
relates to targets, it relates to health inqualities, it relates
to the whole question of Wanless and whether we are fully engaged
or not. It is central to many of the things that I am doing at
the moment.
Q1304 Chairman: In terms of public health
issues and in relation to their importance, where do you rank
obesity?
Miss Johnson: In relation to public
health issues generally?
Q1305 Chairman: Yes.
Miss Johnson: Right at the top.
Q1306 Chairman: Would you say that in
a sense it has overtaken the smoking issue?
Miss Johnson: I think smoking
and obesity are both at the top together pretty much. Smoking
is the largest single cause of preventable deaths so it is hard
not to have it right up at the top too, but both of them are very
major issues facing us.
Q1307 Mr Burns: I was wondering if the
Minister could tell us what the Health of the Nation programme
was in the 1990s.
Miss Johnson: Are you talking
about the White Paper at the end of the 1990s, are you?
Q1308 Mr Burns: No, the Health of the
Nation.
Miss Johnson: I was not a Minister
in the previous government. Preventing causes of death was the
main focus: the premature death from things like suicide and coronary
heart disease and so forth. There was a question where the action
was to follow up some of those issues some would say, but I agree
that some of the same things that were focussed on then, although
probably not obesity as far as I recall it; coronary heart disease,
but not obesity.
Q1309 Mr Burns: You are saying that as
it was the previous government it is not something for you to
comment on, which is a perfectly valid comment.
Miss Johnson: I am aware of it,
but only because I worked for a period in a Family Health Services
Authority. We are looking at the present and the future in the
work that we do, looking only at the past for elements of success
or important pointers to the future; we do not overall spend time
dwelling on it.
Mr Burns: I think that is a fair comment.
The reason I was asking was because of your comment earlier that
you just slipped in where you suggested that everything on public
health started on 2 May 1997 and you did pass a judgment on what
you though had not happened before that.
Q1310 Mr Burstow: I would like to pick
up on the issue of timescales. You talked about the obvious desirability
of reversing trends on obesity. There is no evidence—and
Wanless demonstrates this—that any country on the earth
has so far managed to put in place a programme that has led to
a reversal. Some maybe have started to stabilise. What, in your
view, is a realistic timescale to achieve a stabilisation and
then a realistic timescale to see a reversal in the trends on
obesity?
Miss Johnson: That is something
which we will look at as part of the White Paper process and we
need to engage a lot of people in the question of how we bring
about change. Some countries have actually brought about increased
levels of physical activity. I know the Select Committee has been
to Finland and looked at what the Finns have done on that, and
they have increased—as have a number of other countries
round the globe (although not many)—levels of physical activity
which is obviously one of the strands of the work that we would
want to see happen. However, I think it is very difficult to set
a timeframe on which we would hope to achieve this at the moment
without looking at all the work that is going to feed in and in
particular without engaging in how we are going to motivate people
and enable them to change the choices that they are making. I
think one of the big problems with public health is that at the
end of the day the health of the nation in this regard is quite
a lot down to the individual choices which we all make about whether
we walk to work or catch the bus or go by car; whether we eat
certain things or eat other things and generally how we deal with
food and activity across our lives. That is a very difficult area
to influence and I think that is one of the reasons why it has
proved very difficult internationally. Many other countries have
the same problem as us—or worse, as you are aware—and
it has been very difficult to tackle those problems.
Q1311 Mr Amess: I am absolutely delighted
that when the Health Select Committee decided last year to study
obesity it has had the huge impact that it has on the nation.
I think it is excellent that the Government has responded, because
we all want some action. The Committee looked at your interview
in the Health Service Journal where you suggested that
perhaps a solution was not to eat so much, a little bit more exercise
and passing on those good messages to children. I am not being
rude, but there is nothing really profound in that, nothing particularly
original and in the last 10 years obesity has more than doubled.
Could you share with the Committee, are you content with that
advice or do you think we need a bit more detail in order to make
a real impact and to encourage people to change their lifestyles?
Miss Johnson: That was a setting
out of the two key areas in which change needs to take place and
it is undoubtedly true that if we took more physical activity
of one kind or another—it does not have to be exercise or
sport—and actually ate better and less, then there would
not be an issue. That is indisputable. The question is that there
is an awful lot that may need to be done to underpin that, to
help people to change. That is why we have gone for the White
Paper and for the process of consultation up to a White Paper
in the summer and that is because we are looking to see how we
can best help people, best support them, best engage with the
stakeholders and how everybody could play their role in tackling
what is a very significant issue facing us all, namely obesity.
Q1312 Mr Amess: Just to push you a little
bit further on this, I just wondered where you think the balance
lies between individual personal responsibility in this matter
or making our environment less conducive to people becoming fat.
What do you think the Government's role in all this should be?
Where do you think the balance lies?
Miss Johnson: I think there needs
to be a balance, is the answer to that. I think there is a balance
between government providing probably frameworks and certain things
that support people and actually making sure that a lot of other
things are put in place by others to think about how they can
play a role in helping individuals. Of course, individuals at
the end of the day need to make those choices. There are many
choices that we all make each day and if those choices are not
being made because the framework is wrong or because the support
is wrong or simply because the individual is not being motivated
to make those changes, then it will make little difference what
government does.
Q1313 Mr Amess: Playing devil's advocate
here, I am slightly concerned that if the Government is going
to pursue this policy that nothing really will change, is the
Government not thinking about any legislation in this area? I
am thinking about advertising, labelling calories on bottles of
alcohol. Is the Government really saying that it is an individual's
responsibility and no to legislation?
Miss Johnson: We are not saying
either of those things. What we are saying is that there needs
to be a balance as I said to you origoinally. There are some suggestions
that have been put forward, some of them are in the advanced stages
of being considered: the Food Standards Agency today is discussing
at its board meeting its recommendations which we have yet to
consider on the question of promotion of food. There is work in
hand going through the processes of coming to a considered view
about all of these things and all of that will come together through
the White Paper in the summer. It is not a long process that we
are involved with at this stage, but I think it will provide coherence
across all the strands of the work. It will actually enable us
to see how we can best do things that will support change and
what the roles of others—including individuals—are
in actually making those changes a reality. It is very easy in
government—as I do not need tell any member of this Committee—to
try to legislate for change or to try to direct change from here.
The truth is that you need a degree of consensus and support and
activity out there if anything that is done centrally is to make
any difference to people's lives in this country. That is how
it should be.
Q1314 Mr Amess: You have told the Chairman
that obesity is at the top of the agenda in terms of public health.
That is a very, very clear statement. In the Health Service
Journal you wrote the article—which I fully agree with—and
it just has not worked.
Miss Johnson: If I thought that
making a pronouncement in the Health Service Journal or
indeed anywhere else of that kind was in itself going to change
the world, then the world would be a very easy place to change.
Sadly that is not the case.
Q1315 Mr Amess: My point is that that
obvious advice which we all understand has not worked, so what
is going to be different this time?
Miss Johnson: It is the opportunity
that comes from engaging people and actually making a concerted
effort across a very wide field: frameworks, activities, provisions
and services which might help, together. If there was a magic
bullet on this then I am sure somebody would have found it. It
is clear from the international experience—which you are
only too well aware of—that nobody has actually found a
magic bullet on obesity and I think it is probably going to be
a whole complex series of changes that need to be made in order
to change the direction of both the increased trend in obesity
and to support people in making changes in their lives so that
they can lead them less obesely and more Healthily.
Q1316 Mr Amess: Among the three departments
Health would take the lead in this, would it?
Miss Johnson: Indeed, but in terms
of things like physical activity some of the other departments
like DCMS have a major role to play. We will be taking the lead
on public health because there is only one minister for Public
Health and only one place that Public Health is singly located
across government, but the role of a lot of other government departments
is absolutely crucial in this. If we want our young people to
be healthier then the work then the work that the Department for
Transport is already doing on encouraging children to walk to
school where that is possible rather than to go by car or by some
other form of transport is the sort of thing that might make a
lot of difference to young people. That is just a small example,
but that is not to say that the Department for Transport has not
had a significant role to play in this; they too—like other
government departments—have significant roles.
Q1317 Mr Burstow: What has been clear
from our inquiry and from a lot of published material is that
we are not just seeing a trend that is affecting particular segments
of the population—although there is some evidence that obesity
rates among the poor part of the population are growing faster—but
there is a shift going on in the whole population. We are all
putting on weight seems to be the conclusion from the evidence
that we are seeing. Given that fact and given the approach you
have outlined which is around engaging people, frameworks and
so on. Can you give us a couple of examples from public health
practice and policy over the last 30 years in which the approach
has been primarily focussed on the end of saying we will affect
a whole population change by trying to affect individual behaviour
and individual responsibility? Where has that been effective in
the past that we might learn from?
Miss Johnson: I think there are
things like the drink drive and belt-up campaigns. They are not
exactly public health but some of those campaigns have substantially
changed the culture of people's thinking about the areas of either
drinking and driving or putting your seatbelt on in a car, for
example.
Q1318 Mr Burstow: Were they not backed
up with regulatory requirements and laws that actually require
people to take those actions?
Miss Johnson: That is why we have
the White Paper process to decide what the right balance should
be and that is why I am not going to be tempted this morning into
trying to speculate about where we will get as a result of the
engagement that we are going through as part of this process,
and through the Food and Health Action Plan and through the Activity
Coordination Team work. We do not want to pre-empt the public
and the stakeholders and yourselves contributing to the question
of which way should we go and how will it most effectively be
done.
Q1319 Mr Burstow: But in making our contribution
it would be ever so helpful to have a better idea of what the
Department and what you feel and think is the appropriate direction.
Will the answers today, where it begins to move into the realms
of policy, be ones where we are told that we have to wait for
the White Paper because it might well diminish the value of this
session?
Miss Johnson: In terms of work
in progress, there is a lot of work that is currently in progress.
That work is going forward in any event. We have not stopped doing
anything; in fact we are driving forward hard on the work that
is already going on on the ground: the pilots and the projects
that we have are being rolled out, are being looked at and are
contributing to this process where they are pilots rather than
actual programmes. Something like the free school fruit in schools
programme, for example, is being rolled out across the rest of
the country. We have a million or so children already receiving
a free piece of fruit; we are extending that to the rest of the
country, 2.2 million children will be covered by the end of the
year on that programme. It is the case that we are moving ahead
with things. There is not some sort of policy freeze gone on in
terms of activities on the ground, but in terms of what is the
right balance and how do people contribute, where is the Government's
role in this, where is the role of the individual, where is the
role of key stakeholders and how ought those things to be tied
together in the most productive way for addressing the issue of
obesity and some of the other related issues, then we very much
want to engage in the process of consultation leading up to the
White Paper in the summer and to allow people to have that discussion.
We will be looking very genuinely to see what people are saying
to us and trying to form a view out of what is said.
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