Examination of Witnesses (Questions 1380-1400)
11 MARCH 2004
MS MELANIE
JOHNSON MP, MS
IMOGEN SHARP,
MS DANILA
ARMSTRONG AND
DR ADRIENNE
CULLUM
Q1380 Mr Bradley: There is a cost to
the Health Service of injuries so you would need to take the view
on whether you think cycle helmets increase or decrease injury.
Miss Johnson: I believe the evidence
is that cycle helmets reduce head injuries in particular and that
is why we are advised by all and sundry to wear a cycle helmet
when cycling.
Q1381 Dr Naysmith: We are moving now
to a different area, the Curry Commission into the Future of Farming
and Food. Clearly farming and agricultural policies have a big
effect on the kinds of subjects we are talking about today. There
was not a lot about obesity and public health in the Curry Commission
report, but it really is implemented by the inter-departmental
Curry Implementation plan and I understand that the Department
of Health has been criticised in that you are not really treating
it with much urgency. This will be a chance for you to say that
that is completely untrue.
Miss Johnson: It is completely
untrue.
Q1382 Dr Naysmith: Whether it is untrue
or not it must represent a really good opportunity to get stuck
in and do something about agricultural policies.
Miss Johnson: Indeed, and I quite
often see Larry Whitty; we meet together whether it is to talk
about food in schools, for example, or whether it is to talk about
the supply chain issues and sustainable food and farming strategies.
I have met and attended on a number of occasions the group that
is taking forward the implementation of the Curry plan. I was
at a press event with Don Curry and Don has been at the stakeholders'
meetings on the Food and Health Action Plan. We are progressing
with that at a good pace and it is on target for Publication.
Q1383 Dr Naysmith: What I mean is, there
will be a real impact from the Department of Health on what is
agreed and decided in this.
Miss Johnson: I think there are
a lot of good opportunities to actually join up the supply chain
issues on the food side and what we are trying to achieve on food
and Health and, indeed, compatible with things like, for example,
competitive tendering arrangements. It is certainly the case that
some of the suppliers of the fruit in schools are actually being
drawn relatively locally to the schools that they are supplying.
When I went down to Kent they were supplying a lot of the apples
and fruit fairly locally from the Kent growing areas into schools
in that neck of the woods or in towards London. That obviously
is subject to tendering requirements and so forth, but there has
been no real problem about making sure that there is a good link
up with some of the policies that we are doing and the sustainable
food and farming issues. We are certainly keen on all sides to
maximise that, compatible with the other constraints which I have
mentioned.
Q1384 Mr Burstow: Following up on this
issue of the food chain, whilst we were in Finland we saw what
has happened in respect of low fat spreads and how the consumption
of those has gone up. The question was put, what has happened
to all the fat that was no longer being used by the dairy industry
to produce butter and high fat milks and so on. The answer was
that it reappeared in other dairy products like cheese, and cheese
consumption has gone up. Is there not an argument and a discussion
to be had between yourselves and colleagues in DEFRA about the
fact that given there is now more processing of dairy foods to
get out the fat, that we need to make sure we bank the health
dividend that comes from taking it out and not put that fat back
into the food chain elsewhere?
Miss Johnson: I certainly think
it would be a loss were we to actually find ourselves in a situation
where we had reduced fat in one area to take in more in others.
Out of the areas of salt, sugar and fat—you asked me earlier
on where campaigns or changes had taken place which have affected
people—I think there is more taking in of low in fat things
than there ever used to be. There is a much wider range of foodstuffs
that are low in fat than there once was. That is not to say that
it is not an issue still and we will be talking with the industry
about what they are going to do on fat further, but it is one
of those areas where in fact quite a change in dietary habits
has taken place in recent times and I would certainly not want
to see us make progress on one element of this just for it to
pop up somewhere else.
Q1385 Mr Burstow: Will you be adopting
the same approach you adopted with salt in actually requiring
fat reduction in foods.
Miss Johnson: That is what I am
contemplating doing, yes; that is the plan that I have at the
moment.
Q1386 Mr Burstow: Do you accept that
some foods can be classified as junk foods?
Miss Johnson: I think we would
all, in common parlance, accept that there are some foods that
would be regarded as junk foods. Certainly in common parlance
people regularly talk about junk foods. I think we all know what
sort of food stuffs are being referred to, broadly speaking. It
is true, of course, that a small amount of any of these foods
or these foods taken in on an irregular basis will not particularly
harm you in themselves. It is the degree of frequency and the
size of portions that is the issue.
Q1387 Dr Naysmith: We had a GP in front
of us who described how, when he was prescribing weight loss medication,
he was asked by his primary care trust to limit his prescribing
and cut it down even though it was medication that was agreed
by NICE should be provided. He said he had never been asked to
limit his prescriptions for treating diabetes or for heart disease
or coronary problems. He thought this was short-sighted and I
just wondered what you think of this, Minister, because clearly
treating obesity would be helpful in diabetes and coronary heart
problems.
Miss Johnson: There is NICE guidance
on the use of medication in the treatment of obesity. I cannot
comment on the individual case because I do not know it at all
nor any of the details around it, but PCTs are actually perfectly
within their rights to query any use of prescribing which does
not appear to be in line with best practice. I think we would
all welcome that because we do not want things that are out of
line with that which cannot be justified professionally to be
happening. However, I am not saying that that was what was happening
in this case; I am just saying that that is the rubric about where
we are on this and in terms of the NICE guidance there is guidance
and that guidance is pretty clear. Within that it is quite clear
that GPs are free to prescribe. Where there may be circumstances
beyond it, it will be a matter for them to justify those on a
professional basis.
Q1388 Mr Amess: There is obviously huge
pressure on young girls to acquire the bodies of supermodels.
Would you confirm, Minister, that the Chief Medical Officer has
concerns about the safety of the Atkins diet?
Miss Johnson: I think that what
we believe on diets is that a balanced diet is the best diet and
we still support that basic approach. I have not personally talked
to the Chief Medical Officer about the Atkins diet so I am afraid
I could not comment on that.
Q1389 Mr Amess: As far as the Health
Service is concerned and helping people who want to lose weight,
are you happy that we have enough dietitians, that we are able
to give people the support they need? We had some excellent evidence
from an organisation called TOAST who provided us with evidence
as to how we could possibly tackle this problem, but are you content
with the Health Service, putting aside all these diets and celebrity
endorsements of these different products are concerned?
Miss Johnson: I think there is
a need for a lot of dietitians. We are, however, finding very
good ways of producing people who have the relevant skills. I
saw, for example, on a visit to Barnsley how a professionally
qualified dietitian has trained up a number of local community
workers to do some of the basic advice to patients which obviously
you do not necessarily need to be absolutely fully qualified to
do. She supervises that work and is enabling a much wider range
of people to be reached clearly with the backup that anything
that requires that degree of skill and professionalism which a
fully trained dietitian will have access to, the patient is still
being supported and covered by that where appropriate. It is one
of those cases where again there are many ways of extending our
skill base and in so doing actually engaging with a much wider
section of the population, getting people who are from the communities
to speak to those groups in those communities that they understand
themselves and where they are coming from themselves, and to couple
that with a degree of sophistication and training which the full
monty dietitian will have at his or her fingertips and to make
sure that that full professionalism still underpins all the services
that are provided to the public. I think we may need more dietitians,
but what I would say is that there are many ways of getting them.
Q1390 Mr Amess: Would you agree with
me that the old method of saying in the GP's practice, "get
on the scales, you are too heavy, better lose some weight"
is not enough unless we have the support to see this through over
the long term.
Miss Johnson: Indeed, and I think
that that is the case with many of these things where the behaviour
changes needed for the individual are known—we all know
as individuals it is quite easy to think that you might know what
the answer it— but doing it is much more difficult. Therefore
I think a lot more active support at a local level with people
who are coming from a place which people find supportive in making
those changes is very, very helpful to them in achieving the sort
of change in behaviour that we might want to see on these issues.
Q1391 Mr Burstow: Earlier on you mentioned
the role that the new GP's contract could play in respect of dealing
with obesity, yet within the areas that are optional, within the
areas that are incentivised within the GP's contract there is
no specific and explicit dealing with the issues of weight gain.
It deals with coronary heart disease and other aspects like that.
Is this not a lost opportunity in terms of the GP's contract to
have actually made sure there was a very clear priority and clear
focus on obesity?
Miss Johnson: I do not agree with
you. I think the new contract actually provides a very great opportunity.
It is one that a lot of GPs are taking and it is not only the
GPs, it is looking much wider at the professionals who are working
with GPs—the nurses, the health visitors and others—and
we have to look much more widely than simply putting it all at
the door of the general practitioner. He or she has a big role
to play, but the new contract is offering people consultations
for chronic disease; many of the chronic diseases including, if
you like, obesity, actually have obesity behind them. We were
talking about diabetes earlier on, for example, and the related
health problems that arise out of that. As I mentioned earlier
on, the whole health promotion and advice to patients is now very
much incentivised under the new contract.
Q1392 Mr Burstow: In that answer you
have demonstrated that the incentive is downstream. It is dealing
with the condition that emerges as a consequence of obesity rather
than actually dealing with the obesity. What, within a GP's contract,
will enable us to go back upstream and deal with the obesity?
Miss Johnson: This is one the
things that we need to look at, how we do make sure that enough
work is done early enough with people. If we are going to make
the gains that we have to make, then obviously what we have to
do is not just treat diabetes well but actually stop more people
getting in a position where they have a tendency to develop diabetes.
Q1393 Mr Burstow: Does the contract deliver
that?
Miss Johnson: I believe it does.
All the health promotion advice work that can go on under the
new contract and is incentivised under it and, as I say, the work
that is being done in extending the role of primary care, the
kinds of things that are being done in the primary care setting—the
professionals that are being drawn in and developed in that setting—actually
mean that more and more patients are getting the time spent with
them on exactly those preventative or early preventative issues
where there is something there, a slight problem growing, and
people are getting much earlier help with it.
Q1394 Mr Burstow: Is it not the case
though that the H=health promotion side is that part of the contract
which GPs do not have to themselves deliver, but they chose to
have other agencies take that task on instead.
Miss Johnson: They will be required
to do this under the new contract from April 2004.
Q1395 Chairman: You have talked about
the need to take action a lot earlier and finally turning to solutions
one of the issues that has come up in a number of our sessions
(which you may be aware of) is the whole question of the role
of the school medical. We can see the concern in all our local
schools where children have significant weight problems and are
obese. We have been wrestling with the most appropriate response
to the obvious problem with those particular children. I wonder
what your thoughts are on going back to the measurement and weighting
machine so that you would then have some very clear figures. You
mentioned being surprised—or the Department was taken by
surprise—by the extent of this, but if we have the measurements
that might be helpful in addressing the individual circumstances
of particular children and doing something about those children
and also being aware of the problem that was building up nationwide
on this particular issue. Do you have any thoughts on that? Is
it a good idea?
Miss Johnson: I think it is one
of the things where we want to look at the evidence of what has
been tried elsewhere. I think in some countries they are trying
this out and there are some parts of the country where some things
like this are being looked at or being done. Obviously on its
own it is not going to change things; it gives you a better idea
of the base line and the degree of the problem, but on its own
it is not going to change things. It would need to be coupled
up with a much wider range of programmes and changes that might
support getting a child to lose some of that excess weight. I
think that one of the things is the role of the school nurse who
is now increasingly focussed on these more health promotion and
disease prevention issues. All schools have access to a school
nurse. I think there is a question of whether we can extend that
role in some way or another, whether that would be helpful or
not.
Q1396 Chairman: Are you looking at this
whole area?
Miss Johnson: We certainly are.
It is an area of considerable interest and I agree with you that
it is one of the venues in which maybe more can be done.
Q1397 Dr Naysmith: All sorts of initiatives
have been talked about and some of them have even been tried all
over government, but now there seems to be a feeling of urgency:
we have actually got to act and do something. The complete failure
of the Health of the Nation with its obesity targets must give
us pause for thought. We tried that and it does not seem to have
worked; we need something more than that. You said in an interview
with the Health Service Journal (that famous interview)
that your gut feeling was that it is in the interest of the food
and drink industry that they do the sensible thing. You mentioned
salt earlier. In my constituency a lot of milling and baking goes
on and I know that that particular part of the food industry has
responded well to reducing salt in their products. They did it
voluntarily and they have even done it some more recently. Some
of them have even suggested to me that they would have done even
a bit more if they had been pushed a bit harder by the Government.
Just before Christmas Alan Milburn said in a speech: "specifically
an ultimatum needs to be placed before the industry that unless
it voluntarily cuts fat, sugar and salt in food within a specified
time frame then tough regulatory action will be taken to ensure
that it does". What are your views on that? Do you endorse
that statement?
Miss Johnson: What I think is
that we need to try to get the food industry to recognise the
fact that there has been a change in people's perception of what
they want from the foods that they are buying which, in my view
the food industry is not moving fast enough to recognise in fact.
I have been saying to the food industry in meetings with them
about salt and other topics that I think it is very important
that the recognise that increasingly consumer demand is that they
want the foodstuffs to help them live healthier and longer lives,
not simply to be fun to eat or to meet a basic daily requirement,
but actually to contribute long term to their health. Obviously
there are a number of areas—salt, fat and sugar and maybe
fibre—where those issues are very much to the fore. That
is why I have gone through the process of saying that I need to
talk with them on each of those topics. The salt plans that I
asked for have largely come in. We are currently looking at those
plans; I think they are probably still trickling in, but we have
got a very large number in and we are looking at those. I think
they are probably varied in their response. It is too early to
say much because you have to look and work out what the implications
are for diet of what they are saying. It is not easy just to read
across otherwise we would be able to give you more of a feel for
that now. You need to do work on that and there Food Standards
Agency and officials in the Department are looking at them actively
at the moment. What we are doing out of that will be to decide
how good those plans are. I am not assuming that they are good;
I am going to look to see how good they are and that is what the
detail will provide us with. Out of that, if we are not happy,
we will go back and say that we would look for more. I do not
know whether that will be the upshot because I have not yet had
the analysis and I think that some of them are offering some very
promising reductions. However, it is absolutely essential that
we get this to happen and it happens across the board.
Q1398 Dr Naysmith: What do we do about
those who do not offer sensible reductions?
Miss Johnson: That is an interesting
issue. I think one of the things that consumer-focussed organisations—particular
those which make and retail food because they relay on so many
consumers all the time buying their products—will realise
that consumer opinion is very important and if the consumer has
considerable power and this Government has considerable power
in this then having your products possibly criticised repeatedly
for their content is probably not something that a lot of the
food industry would welcome very much. That is the sort of thing
which the Food Standards Agency has already done by going through
a number of foodstuffs and highlighting the issues with them.
I think that kind of activity could be stepped up were we not
to see the response that we are looking for. As I said, I have
not had a chance to have the analytical work completed yet on
those salt plans to be able to comment on them, so please do not
take that as in indication that they are either satisfactory or
unsatisfactory; it is too soon to say.
Q1399 Mr Bradley: You have clearly had
important meetings with the food industry over salt and it is
important to work closely with the food industry. Could you give
us an indication of how many times you have met the food industry
to discuss the wider issue of obesity and what have their reactions
been so far to those meetings?
Miss Johnson: We have met them
in a whole number of different contexts; I could not really give
you a number off the top of my head. I have met some parts of
the industry singly and I have met some of the representative
organisations. The discussions have ranged quite widely, including
topics like obesity which are obviously are at the centre of everyone's
focus now. In addition, the food industry has, as a whole, been
very widely engaged through the Food and Health Action Plan, the
stakeholders events, the Don Curry work where there is an involvement,
the Food and Drink Federation, the British Retail Consortium are
involved with these things and obviously officials see the various
representatives of industry and various settings on a lot of occasions.
I would say there has been quite a lot of regular on-going contact,
probably too much to summarise even if I had the figures in front
of me and I am afraid I do not.
Q1400 Mr Bradley: Do you support Demos's
view that there should be a fat tax?
Miss Johnson: No country has a
fat tax. We do not particularly think that that is a way ahead,
but we will look to see what is going on in other countries to
see what their experience is. It may not be a particularly productive
form of answer is our initial take, but it is something we will
welcome the views of others on. It is not something on which we
have made a final decision.
Chairman: Are there any further questions?
No. Well, can I thank you Minister and your colleagues for coming
along today. We have a number of outstanding questions which we
will write to you about. You have indicated there are a number
of points where you would follow up with written answers. We are
very grateful to you, thank you very much.
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