Memorandum by Active Sheffield (WP 09)
Please find a response on the physical activity
elements of the Choosing Health White Paper. The response has
been drafted by the Active Sheffield Partnership, which reports
to the city's Local Strategic Partnership (Sheffield First for
Health). The partnership includes key City Council departments
plus all of the city's four PCTs.
In general, we very much welcome the White Paper
and feel encouraged by many of the proposals relating to physical
activity. However, we have taken time to comment on some key omissions
and on proposals that we feel need strengthening.
1. THE RELATIVE
IMPORTANCE OF
PHYSICAL ACTIVITY
(PA)
Active Sheffield welcomes the emphasis given
to PA in the Paper. However, the importance of PA within the public
health debate has been historically under-estimated. It is unfortunate
that the Paper has not taken the opportunity to correct this,
particularly given the evidence recently presented in the CMO's
report.
PA reduces the risk of all-cause death and in
particular the risks associated with England's number one killer—CHD
(accounts for 39% of all deaths). The British Heart Foundation
recently published data estimating that 37% of coronary heart
disease deaths can be attributable to physical inactivity, compared
to "only" 19% from smoking (Britton and McPherson, 2000).
More importantly, physical inactivity is the
most prevalent risk factor (Joint Health Surveys Unit, 1999; Health
Survey for England, 1988). For example, 63% of men and 75% of
women are not active enough to benefit their health (ONS, 1998).
By comparison, "only" 28% of men and 26% of women smoke
and "only" 41% of men and 33% of women have high blood
pressure (British Heart Foundation, 1998).
Recent work in Canada (CFLRI, 2000) calculated
the relative community impact of inactivity versus smoking, high
cholesterol and hypertension ie the relative impact of inactivity
on all-cause death. It concluded that the relative risk associated
with low activity exceeds that of all the other factors considered.
2. UNDERPINNING
PRINCIPLES
Whilst we generally welcome the idea of supporting
"informed choice", it is concerning that this is not
fully complemented by the essential "underpinning principle"
of key "enabling" measures that will significantly reduce
barriers to physical activity—particularly for those living
on low incomes. There is a danger here of de-contextualising PA
from the wider environmental, cultural and social influences and
instead being seen to promote a "self help" and potentially
"low cost" approach. We believe that major infrastructure
and environmental measures are needed to truly facilitate increased
activity and these we feel are given too little emphasis in the
Paper.
In summary, what is needed is a "whole
systems" approach which encompasses a coherent package of
measures on both the demand side (advice to individuals, marketing
etc) and supply side (facilities, environmental changes and capacity
building in clubs etc). Both need an investment programme to make
them happen. Overall, the paper is reasonably strong on demand
side proposals but falls short on the required supply side measures
and fails to address some of the consequent investment issues
such as the crisis in indoor sports provision (see later).
3. OVER-ARCHING
PRIORITIES
We welcome the fact that "exercise"
is included in these priorities. However, we note the reference
to "over a third of people are not active enough to benefit
their health". In fact, the figure should read "almost
70% are not active enough".
4. MARKETING
HEALTH
We applaud the focus given to the importance
of tackling the so-called "demand side" of health. The
Canadian experience strongly suggests a "contributory"
relationship between social marketing and activity levels ie impact
on awareness, understanding and intent (Canadian Journal of
Public Health, June 2004). However, the Paper suggests that
in terms of the early focus in the marketing strategy, physical
activity will feature only within the context of a wider obesity
campaign. This raises a number of concerns:
— as stated above, physical activity
is one of the most prevalent health risk factors and should command
"its own slot" as a stand alone campaign;
— as the CMO recently confirmed, PA
impacts across 20 or so chronic diseases and should not be confined
to only one;
— the levels of PA required to combat
obesity (60 minutes or more daily) are unsustainable for most
people;
— obesity affects "only"
a minority (20%—albeit growing) of the population and therefore
any PA message within an obesity-led campaign is likely to meet
with a "won't happen to me" response from the vast majority
of the population;
— lastly, evidence from other successful
PA campaigns tell us to avoid "medicalising" the message.
On a more positive note, any campaign to promote
physical activity should take into account the following key points:
— avoid words that carry "perceptual
baggage" such as "sport" and "exercise";
— focus on fun and enjoyment and employ
humour wherever possible;
— associate PA with the benefits that
target audiences value eg for young people valued benefits include
spending time with friends, having fun, playing, gaining recognition
and success;
— focus on those who are "ready
to be active" as well as the least active;
— go beyond the "just-the-facts"
message that typifies many public health campaigns—especially
for young people (eg an hour a day or 5x30 minutes);
— promote a "can do" message
and not a "must do" message;
— emphasise positive messages. Negative
messages usually turn people off—"it won't happen to
me". PA is about getting people to opt in/"starting"
and make a positive choice, unlike smoking which is about opting
out and stopping;
— publicise local successes of "real
people" and encourage people to "join in";
— emphasise simple, inexpensive and
practical changes—"99 top tips to be everyday active"
and "walk a street today".
Finally, the social marketing campaign should
extend its remit beyond simply communicating the right message(s).
It should also include three other key elements—mobilisation
via promotional events; informational guides which support the
"call to action" with information on what, where and
how to be active; influencing by engaging key "influencers"
in the community such as employers, head teachers, youth leaders,
GPs, faith leaders, local government etc—these are the people
who influence the everyday settings in which people can be active.
5. CHILDREN AND
YOUNG PEOPLE
We welcome the focus given to young people.
It is clearly recognised that "activity habits" are
formed in the earliest years. We also applaud the emphasis given
to the Healthy Schools strategy. However, we would suggest a number
of improvements to the proposals:
— there is barely any mention of the
critical importance of play as a source of physical activity—particularly
for pre and primary school age children. Research by UCL (2004)
found that children get more physical benefit from kicking a ball
around in the park or playground than from PE lessons. The study
concluded that the effort of unstructured play burns more calories
than the average of 70 minutes a week of formal games that pupils
get in school;
— we are concerned about the lack of
priority given to pre-school and primary school aged children.
Whilst investment in secondary schools is welcome, for too many—especially
girls—the resources are coming too late;
— we need to see a greater commitment
to lesson time PE given the difficulties that many children—especially
those from low income families—have in accessing after school
programmes;
— there needs to be much greater focus
on the role of parents and the influence of the family in supporting
active lifestyles. Inactivity is very much inter-generational
and a schools-only approach will often not be sufficient to break
this cycle;
— there needs to be greater emphasis
on non-school activities ie community-based physical activity
for young people. From birth to the age of 16 years, a child spends
only 9 minutes of every waking hour in school. We need clear policies
that encourage and support physical activity in the remaining
51 minutes!
— there is still too great an emphasis
on sport and traditional team games within the school sport partnerships.
Whilst this is fine for some children, we know that traditionally
the majority have been "turned off". Many young people—especially
girls—are attracted by more individual-type activities such
as dance, walking, cycling and aerobics;
— the focus in schools should be on
health-related physical activity—which includes, but goes
beyond, just sport. The role of physical education as the "spring
board" for developing interest, confidence and skills in
activity should be emphasised—PE should aim to truly "physically
educate" young people. The Paper should recommend this more
comprehensive approach to PE within schools as part of its strategy
for promoting informed choice;
— the support for cycling and active
travel plans is welcomed. However, once again, these "tactical"
measures must be coupled with more strategic proposals to tackle
the wider infrastructure and environmental conditions. For example,
cycle parking and lockers will remain largely irrelevant if safe,
direct and segregated cycle lanes do not link the local community
with its school
6. LOCAL COMMUNITIES
LEADING FOR
HEALTH
We very much welcome the importance attached
to the role of local government in promoting health and in particular
the centrality of local authority and PCT partnerships working
at the local level. We also welcome the expected flexibility offered
by the new Local Area Agreements. However, we would wish to see
a requirement that promoting physical activity form a key element
of the work of all LSPs and LAAs.
The references to "whole town" approaches
to active travel are to be supported. However, the commitment
and follow-through on this appear to be rather vague. Similarly,
there is mention of the forecasted 7,000 miles of new cycle lanes,
but this is from already committed resources. Where is the vision
of how we will move towards a European-standard provision of integrated
cycle and footways?
The greater use of pedometers is to be welcomed.
However, in the continuing absence of a serious strategy to promote
a walk-friendly urban environment, we will continue to see a continuing
decline in the numbers of people walking. We would have wished
to see greater emphasis given to walking as the single most-important
activity that can drive activity levels upwards. Pedometers will
not overcome the real barriers to walking such as poorly lit routes,
disconnected path networks, inadequate signage and benches and
(perhaps most importantly) excessive and speeding traffic.
It is surprising and disappointing that no mention
is made of stair climbing as a potentially significant means of
increasing daily activity levels. Stair climbing requires high
energy output—8-11 Kcal per minute—which is high compared
to many other forms of physical activity. Even climbing two flights
of stairs daily can lead to 2.7Kg weight loss in a year (Physical
Activity Unit, Canada 2003). Stair climbing is an activity which
is accessible to virtually all the population and can easily be
built into daily routines. An international physical activity
conference in 1998 concluded that the most successful exercise
interventions in the past 20 years were stair-climbing initiatives
(Sallis et al. 1998).
The suggested best practice guide on free swimming
would be helpful. However, once again there is concern that the
real issue here is not the lack of ideas within local government
but instead the lack of resources to support the consequent loss
of income. Given the clear health economics in support of physical
activity, one has to wonder why the rationale underpinning the
Government's much-welcomed investment in free museum access does
not equally apply to supporting (perhaps selectively) free access
to physical activity. This is particularly the case with swimming—which
is the second most popular activity and has safety as well as
health benefits. An example of a cost-effective and targeted method
of supporting "free swimming" might be to offer free
"top up" lessons for those children who fail to achieve
the minimum 25M during school swim programmes. Given that many
of these children are invariably from low income families, the
measure will also impact on reducing health inequalities.
Our concern about the lack of investment in
key infrastructure was mentioned earlier. Sports facilities—including
swimming pools and parks—are vital elements in this infrastructure.
Indoor sports facilities are used more than any other setting
for sports participation and yet we know that the national stock
of sports centres requires around £550 million to be spent
immediately. There is only passing reference (in Case Study sections)
to these facilities. The White Paper Delivery Plan must identify
(or commit to identifying) a feasible way forward on this facility
crisis. Arguably the only sure way of making progress is to place
a statutory requirement on local authorities to provide and maintain
"reasonable" level of facility provision. This may then
halt the downward trend in local government spend of sport (expenditure
on sport by local authorities has fallen from £18 per head
in 1998 to £12 in 2002). In the UK government spend on sport
is only £21 per head per year compared with £112 in
France. This under-investment is already adversely impacting on
sports participation as the GHS 2002 clearly demonstrates.
The Paper talks about health inequalities in
Chapter 1. However, it fails to develop the case for specific
actions for selected target groups. There is a real danger that
a strategy that largely focuses on social marketing and informed
individual choice will lead to greater inequalities in terms of
activity levels. Evidence from Finland and Canada suggests that
targeted approaches can help to increase activity levels amongst
"least active" groups. We would therefore suggest that
the Paper's current focus on young people should be complemented
by an equal focus on older people. There are a number of reasons
for this:
— 60% of those over 60 years are inactive;
— Sport England's Sport Equity Index
confirms that the group least likely to take part in sport is
"70+ DEs". This means that this group is 87% less likely
to take part in sport than adults generally;
— there are more people over 65 than
there are under 16;
— low income households feature disproportionately
amongst this group;
— amongst those over 65, a significant
number of deaths are attributable to falling—exercise can
have a major impact on falls prevention and recovery;
— many experts are of the view that
no segment of the population can benefit more from exercise than
the elderly (American College of Sports Medicine).
Despite this, insufficient work to encourage
physical activity has been done with this growing population group.
The proposal for PCTs to work more closely with
football clubs appears to be disconnected from any broader strategic
theme within the Paper. This should fit within the wider social
marketing strategy and must be clear about the intended message(s)
and the likely audience.
7. NHS HEALTH
TRAINERS
An acknowledgement of the importance and complexity
of behaviour change is welcomed and we would broadly support experimental
work with Health Trainers. However, a number of critical issues
must be considered:
— all primary care staff—including
GPs—must be better engaged with the preventative agenda
and in particular with physical activity. The danger in creating
specialist roles (Health Trainers) is that this wider engagement
is made even less likely (the "it's not my job" syndrome!);
— physical activity must be given equal
prominence within the scope of advice available from Trainers;
— advice to clients must include both
structured (facility based) options and lifestyle (no or low cost,
often home-based) options;
— the social marketing campaign must
create clear and simple physical activity messages—including
audience specific messages—to be used in primary care settings;
— the early development of the proposed
Patient Activity Questionnaire is a critical pre-requisite to
the success of the advisory scheme;
— it must be recognised that there
is little evidence of any long-term impact of advisory/counselling
services based in primary care settings (Emmons and Rollnick,
2001). It should also be of concern that the cost of establishing
such "downstream" services would not be easily sustained
by absorbing them into mainstream general practice;
— it is once again critical to emphasise
that without policies that support environmental and infrastructure
improvements, advice within primary care settings will have little
sustained influence on patient activity levels.
In conclusion, we recommend that this proposal
is taken forward with care and that wherever possible both a whole
systems approach (including environmental and infrastructure changes)
and strong evaluation measures are put in place at the same time.
8. A HEALTH-PROMOTING
NHS
We clearly support the concept of the NHS moving
towards a more preventative role. However, given the threat posed
by inactivity (discussed earlier) it is concerning that there
is little mention of physical activity in chapter 6. There is
significant potential for primary care staff to positively influence
physical activity levels. However, at the moment there is little
incentive in terms of the current performance management systems
(in primary care) for physical activity to be given priority.
The current requirement for PCTs to have a physical activity policy
is a start but it is not nearly enough.
A new strategic approach to fully engaging and
supporting the primary care sector to promote physical activity
is required. This must ensure that physical activity is part of
the care pathways for medical conditions; that the promotion of
physical activity is a routine part of practice consultation and
that physical activity features in all relevant performance management
systems.
9. WORK AND
HEALTH
We very much support the proposed inclusion
of health within the IiP standards for 2007.
Whilst we wouldn't disagree with the idea of
tax-efficient bike purchase schemes, we must re-iterate the essential
point that such "downstream" measures aimed at individuals
will fail hopelessly without the "upstream" environmental
measures needed to make cycling safe, convenient and enjoyable.
10. A PHYSICAL
ACTIVITY PROMOTION
FUND
Whilst any additional funding is to be welcome,
we would strongly urge that such a Fund is dovetailed with and
complements existing funding for sport and physical activity.
Local government is keen to see a "single pot" for sport
and physical activity (drawing together the different funds) and
would ideally wish this to be allocated to a local physical activity
partnership (perhaps within the `health' arm of the local LSP).
The partnership would then be required to produce a plan (with
identified projects, costings and outputs) submitted for approval
before being allowed to draw down the allocation.
11. REGIONAL
PHYSICAL ACTIVITY
CO -ORDINATORS
There must be clarity as to the role of these
posts and consultation should take place with local partners in
each area to ensure that "added value" results from
such appointments.
12. THE VOLUNTARY
SECTOR
If the activity targets set by "Game Plan"
are to be met then this will place significant pressures on the
voluntary sports and physical activity clubs in the community—pressures
that they are currently unable to meet. Urgent and much greater
investment is needed in the infrastructure of these clubs. Whilst
initiatives such as "Step into Sport", "Club Mark"
and CASC are helpful, they are not enough. Radical increases in
participation will require more significant and sustained investment
in the voluntary sector.
13. MAKING IT
HAPPEN—NATIONAL
DELIVERY
There is a need for greater clarity about the
respective roles of the DoH and DCMS/Sport England. For example,
there appears to be a danger of both Sport England and DoH working
in parallel on potential social marketing initiatives. There is
also occasional apparent inconsistency about the scope of Sport
England's interests eg does it include walking or not?
If Sport England are to take a lead on the social
marketing strategy they must take heed of the dangers of using
"sport" as part of the headline messages and they must
fully embrace "lifestyle" activities such as gardening,
taking the stairs etc (as the recent NE pilot appears to have
done).
At times Sport England claim to have a single
focus on "sport" ie competitive and organised activities
such as rugby, football, cricket, swimming etc. At other times,
its attention ranges across "lifestyle" activities such
as walking, cycling, dance etc. (ie non-organised, informal and
often individually-based activity). Clarity and consistency would
be helpful on this important issue. One view would be that the
DoH take the lead on the lifestyle activities and Sport England
lead on sports activities. Clearly there would need to be close
and on-going dialogue between both organisations—particularly
on issues such as the social marketing strategy.
14. MAKING IT
HAPPEN—LOCAL
DELIVERY
Much greater co-ordination is needed of physical
activity programmes and projects at the local level. Too often
local government falls back on a narrow facility management role,
whilst PCTs too often have little capacity or inclination towards
physical activity. It is recommended that each locality is required
to form a physical activity partnership involving local government,
the PCTs and where possible commercial and voluntary sector agencies.
This should form part of the LSP (preferably under its "health"
arm) and be required to produce a local physical activity strategy
and to oversee its implementation.
It is extremely unfortunate that the White Paper
has not taken the chance to realign PCT boundaries with those
of local authorities. This would provide a much stronger platform
for joint planning and working.
15. CONCLUSION
Overall the White Paper represents a significant
step forward in the public health debate. It also gives greater
prominence to physical activity than has hitherto been the case.
The recognition of the need for social marketing is very much
welcomed, as is the importance afforded to individual behaviour
change programmes.
However, the Paper places too little emphasis
on key infrastructure and environmental measures that are needed
to support the marketing and behaviour change programmes. It also
fails to follow through the health inequalities issue with targeted
programmes for the least active—especially older people.
Finally, the Paper misses the chance to articulate
the truly prominent role that physical activity can play on the
wider public health agenda. Inactivity poses the most pervasive
public health risk in England and should therefore be treated
as a "stand alone" issue in its own right, rather than
its proposed status as sub-text within the obesity debate.
January 2005
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