Memorandum by the National Heart Forum
(WP 97)
PURPOSE
To set out the National Heart Forum's (NHF)
initial views on the Choosing Health White paper to the Health
Select Committee.
There is much to commend in the White Paper
however we do have concerns which we have set out below within
the framework of the Health Select Committees three questions
and hope these will be addressed in the delivery plan due to be
published in the next few months.
ABOUT THE
NATIONAL HEART
FORUM
The National Heart Forum is the leading alliance
of 48 organisations working to reduce the risk of coronary heart
disease in the UK. Member organisations represent the medical
and health services, professional bodies, consumer groups and
voluntary organisations. Members also include many individual
experts in cardiovascular disease research. Government departments
have observer status.
The views expressed in this submission do not
necessarily reflect the opinions of individual members of the
alliance.
OBSERVATIONS AND
RECOMMENDATIONS
A. General opinion and introduction
The NHF welcomes the Choosing Health public
white paper, which if properly resourced and fully implemented
is a good start in moving towards "fully engaged scenario"
as described by Derek Wanless in the Treasury review of public
health investment—which was the stimulus for the white paper.
The White Paper is thus a good start for public
health as it sets out an initial three-year programme of action
on which to build sustainable foundations for public health. Very
significantly 10 of the Department of Health's 20 Public Service
Agreements are now public health. The White Paper sets out an
ambitious programme of change with the main aim goal being to
mainstream public health in the NHS and schools and ensure greater
engagement of Local Government. If successful this will bring
about a long overdue cultural change to promote health. One billion
pounds is the biggest single new investment in public health in
England. For the first time a public health white paper sets out
a clear set of state level responsibilities and public health
rights that once and for all should end the nonsensical debates
about the nanny state. Public health functions and organisations
are to be strengthened, particularly social marketing, research
and development, information, development and performance management.
The White Paper goes a long way to establishing
for the first time a comprehensive cross sectoral approach to
preventing obesity.
Most importantly the White Paper combined with
the children's national service framework have for the first time
since the start of the NHS, established a national plan of action
to promote the health of children and young people. Most of the
recommendations of the National Heart Forum's young@heart policy
framework are addressed in the White Paper with the exception
of play which we hope will be identified in the DH's physical
activity plan which should include wider government action from
other government departments.
B. "Whether the proposals will enable
Government to achieve its public health goals?"
Resources
— A major critical success factor will
be to ensure that the resources to deliver the plan are made available
and go for the purposes intended. In launching the new white paper,
the Secretary of State for Health announced that the Government
would make available one billion pounds over the next three years.
(2005-6/2007-8). The NHF has concerns that within the spirit of
"the new localism" local NHS primary care and acute
trusts could divert the money for other purposes—they have
sovereignty over these resources. Given the pressures on PCT's;
the public health targets could be seen as long term deferrable
deliverables and could be postponed especially as they are difficult
at this stage for the Department of Health and the inspection
agencies to properly scrutinise. The NHF recommends that a fully
costed three year delivery plan be made publicly available and
a clear audit trail is kept to ensure that the Department of Health
and the NHS utilise the resources solely for public health investment.
This should be scrutinised by parliament through the HSC and through
the National Audit Office. The NHF also recommends that the HSC
keeps a watching brief to ensure that further resources are made
available for 2008-09 onwards to stay in line with the public
health investment recommended by the Treasury's reviews undertaken
by Derek Wanless (2003 and 2004). The NHF would like a public
statement on the Governments commitment to the public health components
of the "fully engaged scenario" Does the Government
accept the scenario and will it invest accordingly in public health
developments.
— There are no quick fixes to address
the lack of historical investment in public health. The success
of the strategy will depend upon the quality of the delivery plan.
The fundamental message from the Treasury's Wanless review of
public health makes clear the need to undertake public health
properly. The NHF recommends that the DH prioritises public health
infrastructure developments as its first priority to provide a
public health system for England that is capable of delivering
the ambitious programme of action.
— The Choosing Health white paper states
that the Secretary of State will coordinate action nationally
through a new Cabinet subcommittee that will oversee joined up
development and implementation of the government's policies to
improve public health and reduce inequalities [pg 177:12]. The
NHF has concerns about the lack of any substantial input from
the Department of Transport and hope that this will be addressed
in the physical activity plan which should include wider Government
action. Indeed the Department of Transport is notably absent at
all DH physical activity meetings. Likewise the food and health
action plan needs to include real buy in from other government
departments. The critical question is what happens if they do
not co-operate as this is so often the nemesis of effective public
health action. Clearly the Secretary of State has assumed a greater
responsibility for public health than his predecessors but it
is unclear if he or through the mechanism of the newly announced
cabinet sub committee will have the necessary powers to ensure
that public health is a key consideration in all government policy,
particularly departments such as department for transport where
health promotion is not a central consideration and polices are
sometimes in conflict with efforts to promote health.
Tobacco
— The exemption to the smoking ban
in enclosed public places is highly undesirable as this is likely
to worsen health inequalities, fail to protect bar staff and encourage
pubs to stop selling food to escape the ban (which is counter
to the Government's drive to reduce harmful drinking) The position
in England will become increasingly anomalous and anachronistic
as a complete ban is likely in Scotland and Wales in addition
to the very successful ban in Ireland. We believe the Government
has misjudged the public mood and should take further steps to
secure a total ban. The NHF recommends that the Government immediately
invests in a public education campaign to prepare the ground for
a full ban to be introduced by the time the Government intends
to take forward and then strengthen the necessary legislation
for England.
Nutrition
— The NHF was pleased to see that the
white paper defined a clear set of principles for the role of
the state in public health but regretted that these were not interpreted
in all avoidable chronic disease risk factor areas equally. In
particular action on food, nutrition and physical activity lags
significantly behind the comprehensive action taken on tobacco
and smoking. In respect of nutrition and obesity the NHF believes
that the priorities for Government should be developing consumer
friendly nutritional profiling/signposting of all processed foods,
effective regulation of the food and marketing industries and
school food. We do not believe that self regulation of the food
and marketing industry will be effective given the global nature
of these highly competitive industries. The WHO announced in December
2004 that self regulation of the food industry will not work and
other forms of regulation need to be enacted. Obesity increased
by 400% in the UK in the last 20 years and it will probably take
20 plus years for the obesity epidemic to be reversed even if
the government take a "fully engaged" approach. Given
the rate of increase in obesity in the UK—the fastest in
Europe—any further delay on effective action will worsen
the situation. Radical action is needed immediately. There is
little indication of meaningful action from the producers of low
nutrient value, salty and energy dense foods. The food marketing
activities and claims of progress require close monitoring for
implementation and impact. Often reforms are claimed but do not
materialise or are of no significance. The European Union Health
Commissioner Marcos Kyprionou has signalled that the European
Commission may take legislative action within one year if the
industry does not reform. The UK government agenda is already
out of kilter with Europe and the WHO therefore the NHF recommends
that (1) the UK government in the absence of comprehensive
industry wide action, advances its review to early 2006 on legislative
action to control the marketing of foods high in salt, sugar and
fat to children and young people and on the provision of consumer
friendly "front of pack" nutritional information on
all processed foods. (2) The UK takes a lead in its forthcoming
presidency of the EU to champion a pan European approach to nutritional
profiling and signposting (similar to that being pursued in the
UK) for action on food composition, labelling , promotions and
health claims (3) In the meantime establishes competent monitoring
systems for all forms of food marketing in England.
— We would like to see nutrient based
standards underpinning the supply and inspection of all school
food. Achieving rigorous school meal standards will be important
in setting similar standards in other public settings. The NHF
would like to see minimum expenditure levels for school meals.
The current situation is iniquitous. Adequate resourcing of the
"food in schools" programme is vital to achieving the
obesity target.
Physical activity
— The National Heart Forum awaits the
long overdue national physical activity plan which we hope will
address the following issues.
— The NHF would like to see the full
contribution of other government departments in the production
of the national physical activity plan. (see note above on role
of Secretary of State for Health) In particular the NHF believes
that this has led to a lack of attention to the important role
of a health supporting environment with an emphasis on individual
behaviour. Particularly in respect of transport policy and the
built environment.
— The NHF believes that actions to
support children's play are a serious omission from the White
paper especially given the importance of play in child development
and the need to motivate the unengaged and inactive. Play offers
a key strategy to meeting many Government policy goals as well
as the physical activity and obesity targets.
Hypertension
— The NHF continues to be concerned
about the need to have a nationwide strategic approach to the
prevention and management of hypertension. The potential health
gain is huge, thus it is surprising that it is not included more
comprehensively in the white paper.
C. "Whether the proposals are appropriate,
will be effective and whether they represent value for money?"
Social marketing
— The NHF is pleased about the increased
investment in social marketing of health; if done properly this
will be a key investment for positively altering the UK's food
and physical activity and health culture. However we have concerns
about alcohol and food and marketing industry organisations having
any involvement in the implementation of this work as this could
dilute its effectiveness. This would be through two means—partnership
compromise and by sending confused messages to the public. We
believe the role of industry should be complementary and set against
Government determined standards. The evidence from public health
literature is that the public wants to be informed from an independent,
authorative and credible messenger. The NHF recommends that any
funding from the alcohol, food and marketing industries should
be administered through a blind trust with independent governance.
We believe in a dialogue with industry but have concerns about
the inevitable trade offs that arise from inappropriate partnerships.
— There are conflicts of interest between
the marketing industries in working for the food industry and
Government which are not necessarily in the best interests of
the public. We note this was a concern of the recent HSC review
on Obesity. We do not feel this has been addressed and is a value
for money issue and a positive lever the Government could employ
to shape the market. We recommend that the Government should set
similar standards with the food (and alcohol) industry as they
did for tobacco and not allow any marketing company to bid for
Government sponsored information campaign contracts if they also
market products high in fat, sugar and salt to children and young
people.
— From the perspective of the appropriate
usage of public resources the NHF believes here is plenty of scope
to explore utilising taxation and fiscal incentives to shape the
market for health. We feel that the Treasury has not given the
Health Select Committee an adequate response to the recommendation
about reviewing VAT on foods made in its enquiry on Obesity. If
the government is serious about the "polluter must pay"
principle to which it subscribes then the NHF feels that there
should be further exploration of levies on health damaging industries
for improving the public's health This works well with the energy
industries. Why could it not apply to others such as food, alcohol
and tobacco.
Measuring success
— The Summary of Intelligence supplement
to the White paper states that success in raising physical activity
levels will have been achieved if there is a 3% increase in the
prevalence of people undertaking at least 30 minutes of moderate
intensity sport at least three times per week. It is unclear why
this target has been chosen since it does not relate to the target
set out in Game Plan. (70% of population active by 2020) or to
the CMO's recommended levels of physical activity for health (30
minutes moderate intensity activity on at least five days of the
week). It also specifically mentions "sport" rather
than "activity" which is surprising. The NHF believes
that the national target should be similar to Scotland's ie A
1% year-on-year increase in the prevalence of people achieving
the CMO's recommended levels of activity for health.
— The White paper states that the government
will sponsor debate on corporate citizenship across the public
sector that will lead to firm recommendations for public and private
sectors to demonstrate how they can organise their activities
in ways that improve the health of employees and the wider community
[pg 96: 65].
— The White paper fails to emphasise
the role that the NHS has in encouraging staff and patients to
travel to and from its sites by foot, by bicycle or by public
transport. One of the targets set out in the NSF for CHD is for
the NHS to introduce travel plans and this would have been an
ideal opportunity to reiterate the benefits that such travel plans
can have on health by increasing physical activity levels.
— The Department for Transport will
work with the cycle industry to produce user-friendly guidance
on the tax-efficient bike purchase scheme to promote cycling [pg
165: 22]. The NHF believes that the opportunity should have been
taken to explore other fiscal incentives to encourage behaviour
change, such as employer tax breaks if health-promoting facilities
are provided on-site.
— The Investors in People Standard
will develop a new healthy business assessment for incorporation
when the Standard is reviewed in 2007 [pg 166: 27]. It is unlikely,
however, that this will have much impact on small and medium enterprises,
for whom tax-breaks would be more of an incentive.
D. "Whether the necessary public health
infrastructure and mechanisms exist to ensure that the proposals
will be implemented and goals achieved?"
— The NHF welcomes the developments
in strengthening the public health infrastructure which as Derek
Wanless identified is weak from years of under-funding and under-development.
However we have concerns about the very limited capacity within
the DH civil service establishment, the need to develop a joined
up public health system for England, insufficient investment planned
for developing the public health system, the need for an independent
public health institute and lack of public health watchdog(s)
on the tobacco, alcohol, food and marketing industries as well
as the capabilities to organise and deliver competent social marketing
campaigns. The NHF have made the case in previous submissions
to the Department of Health and the Health Select Committee. We
are astonished that the DH civil service dedicated establishment
for public health is being cut at a time of apparent expansion
for public health investment. This is a time to ensure that DH
has the requisite number of civil servants. There are as little
as four, two and two civil servants working respectively on tobacco,
physical activity and nutrition which will have serious consequences
for the quality of the delivery of the white paper.
— The importance attached to the promotion
of physical activity needs to be increased. The NHF believes that
the situation could be improved by establishing a standing expert
committee on physical activity akin to those on nutrition and
tobacco.
— The NHF welcomes the development
of public health organisations but would like to see a joined
up public health system for England developed along the lines
of those in Scandinavia, Scotland and Wales. We have particular
concerns about the lack of a dedicated government funded organisation
to commission sophisticated social marketing campaigns. The white
paper does not clarify the situation as to how such work is to
be taken forward.
— The NHF believes that an important
part of the fully engaged scenario is to achieve a fully engaged
corporate sector and move towards a health promoting economy.
To achieve this we would like to see public health watchdog/regulatory
organisations for controlling the whole spectrum of the marketing
of food, alcohol and tobacco.
— The NHF welcomes the commitment to
health impact assessments of government policy and action. We
would like to know when this will happen and the scope for the
assessments and if the government will establish an independent
mechanism such as a public health institute to undertake the work
in a transparent way. The NHF would also like to see the health
impact assessments and regulatory impact assessments made available
to Parliament, Select Committees and the Governments regulatory
and inspection organisations.
Finally the NHF does not want "Choosing
Health" to be what Derek Wanless described as "yet another
public health report that gathers dust on the shelf". The
NHF will be playing its part to ensure this does not happen.
January 2005
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