House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Annex

The Royal College of Physicians welcomes the opportunity to respond to the "Choosing Health?" consultation. Our response focuses on four key public health issues: smoking, alcohol, obesity and sexual health.

The College has played a leading role in addressing public health concerns for much of the past 50 years, most notably in the area of tobacco control. Its work has, and continues to be, informed by the experience and expertise of our Fellows and Members who deal with the consequences of unhealthy behaviour, often seeing patients who are suffering from the combined effects of smoking, alcohol misuse, obesity and sexual disease.

We note that much of the current debate about public health has focused on the pros and cons of "government intervention" versus "individual responsibility". While we support the notion of freedom of choice, it is clear to us that the serious medical consequences of smoking, obesity, excessive alcohol and sexually transmitted disease requires decisive leadership and action by Government and can only be successfully achieved through:

— regulation or legislation, as history has compellingly demonstrated in the case of smoking and tobacco control; and

— cabinet-level cross-departmental co-ordination of policy development and implementation on public health issues.

Smoking, alcohol, obesity and sexual health have much in common with each other in terms of the challenges facing Government, industry, health professionals and society. In particular:

— All disproportionately affect the vulnerable in society, the young, the deprived and the disadvantaged.

— All require more socially responsible approaches to the advertising, marketing and promotion of products, which, if used at all in the case of tobacco, or unwisely in the case of alcohol and diet, cause ill-health and premature death.

— Premature death and ill-health from the above causes are preventable, and could be significantly reduced by public education and health promotion to encourage healthy behaviours.

— All form a substantial cost to society, not just through the costs to the NHS, but also in terms of wider costs to society such as lost production, costs to social services, and reductions in quality of life.

— All have implications for the training and education of health professionals and their practice.

In our response the College identifies clear actions and measures that should be taken to address these challenges. Our response also incorporates the views of the College's Patient and Carer Network.

RCP Patient and Carer Network

"Government should not be afraid to regulate."

We hope that the forthcoming White Paper will incorporate many of our recommendations as part of a coherent and long-term programme of policy and practice. But, above all, we urge Ministers to embrace the need for tougher regulation and cross-departmental co-ordination as levers for achieving real change. If they do, it will be the clearest signal yet that the Government is serious about tackling our nation's ailing public health.

TOBACCO

LONG-TERM OBJECTIVES

The long term objective of public health policy and practice in relation to smoking in Britain should be to achieve a smokefree society.

In practical terms, with strong leadership and commitment, and with creative use of alternative nicotine products, this could realistically be achieved in 20 years.

MEDIUM-TERM OBJECTIVES

To achieve a fully smokefree society we propose measures to:

— Reduce the prevalence of smoking as quickly as possible, by

— maximising cessation rates among established smokers;

— minimising the uptake of smoking by young people;

— Maximise the use of alternative, safer sources of nicotine by established smokers who are unable or unwilling to quit.

What is the context of these objectives?

1. The size of the problem

— There are currently about 13 million smokers in Britain.

— Smoking currently kills around 114,000 Britons each year, far more than any other avoidable cause.

— Smokers who die in middle age as a result of their smoking lose on average 21 years of life.

— Smoking causes a vast burden of premature illness amongst smokers and non-smokers, including young children.

— Smoking exacerbates poverty and deprivation.

— Smoking contributes to social inequalities in health in Britain more than any other identified factor.

2. Smoking as an addictive behaviour

— Smoking is a powerfully addictive behaviour, and most adults continue to smoke because they are addicted to nicotine rather than from choice.

— Most smokers become addicted to nicotine during or before adolescence, and once addicted find it very difficult to stop smoking.

— Hence, two-thirds of all smokers would prefer to be non-smokers but only a very small proportion (currently only about one in every 70) succeeds in quitting each year.

— Nicotine is not itself a significantly harmful drug; it is the tar that accompanies nicotine in cigarette smoke that accounts for most of the harmful health effects of smoking.

— Nicotine addiction per se has none of the adverse societal effects associated with addiction to alcohol or illicit drugs; it is tobacco smoking as a source of nicotine that is harmful.

3. Implications for health policy

— Therefore, whilst quitting smoking is the ideal course of action and should be promoted as the best outcome for all smokers, it is also important to address the needs of the substantial proportion of smokers unable or unwilling to quit in the short to medium term.

— For these smokers, switching to a safe source of nicotine offers almost all of the health benefits of smoking cessation with minimal risk.

— Effective prevention of the current burden of ill-health and mortality caused by smoking therefore requires three courses of action:

1. Measures to prevent uptake of smoking by young people.

2. Measures to encourage complete cessation in current smokers able to quit.

3. Replacement of smoked tobacco products by alternative safer nicotine sources for those unable or unwilling to overcome their nicotine addiction.

What policies are available?

The following measures have been shown to be effective in relation to the above three areas, either in their own right or as part of an effective overall policy in reducing smoking prevalence in other countries:

— Comprehensive, total smokefree policies in all public and workplaces.

— Progressive increases in the real price of smoked tobacco products, combined with effective measures to tackle smuggling and "faghouse" distribution.

— Strong and sustained health promotion programmes.

— Complete prohibition of all advertising and promotion of smoked tobacco products.

— Systematic implementation of smoking cessation services and encouragement of use.

— Promotion of safer forms of nicotine delivery as an alternative to smoked tobacco.

LIKELY TIME COURSE OF THE EFFECTS OF DIFFERENT POLICY APPROACHES

1. Policies that reduce uptake of smoking:

— Minimal effect on major diseases (cancer, heart) over next 20 years.

— Substantial reduction in risk of major diseases from 20 years onwards.

— Substantial and rapid reduction of peer group and role model smoking norms.

— Immediate reduction of passive smoke exposure to others.

— Immediate reduction of parental role modelling of smoking and passive smoke exposure (pre- and post-natal) to own children.

2. Policies that increase smoking cessation:

— Immediate reduction in risk of most major smoking-related diseases.

— Immediate reduction in health service use and improved productivity.

— Immediate reduction in smoking role models and societal norms.

— Immediate reduction in all passive smoking exposure.

3. Policies that reduce the harm caused by nicotine addiction:

— Immediate reduction in risk of most major disease.

— Immediate reduction in health service use and improved productivity.

— Immediate reduction in smoking role models and societal norms.

— Immediate reduction in all passive smoking exposure.

What Should UK Policy be on Smoking?

1. Reduce the drivers to smoke in everyday life

There is strong evidence that the main driver to uptake of smoking by young people is the prevalence of smoking among adults, and the resultant perception of smoking as a positive adult behaviour. Policy should therefore be directed primarily at areas (2) and (3) above.

The following general policies help to make smoking generally undesirable and/or unacceptable, and thus create an environment in which smokers are more likely to try to quit, and young people less likely to want to experiment with cigarettes and become regular smokers:

— Make all work and public places completely smokefree.

— Strengthen the current advertising ban by complete prohibition of all sponsorship, brand stretching, product placement and point-of-sale promotion of cigarettes.

— Strong and sustained publicity/advertising campaigns targeted at all sections of society and all aspects of smoking, including passive smoking.

— Progressive and substantial increases in the price of cigarettes (in conjunction with changes in the availability of alternative nicotine products, and controls on smuggling, see below).

— Prohibit all point of sale promotion and display of cigarettes and smoking tobacco products (make cigarettes an under-the-counter product).

— Impose plain generic packaging on all smoking products.

— Act quickly to close any loopholes or unforeseen exclusions to the above.

2. Maximise the uptake of effective smoking cessation interventions

Effective methods of cessation exist and are available in the UK for all smokers to use; however, the proportion of smokers accessing cessation services, the proportion of doctors trained in and actually delivering cessation interventions, and the proportion of consultations with smokers in which smoking is addressed remains low. We therefore propose:

— Powerful, pervasive and sustained advertising and promotion campaigns at national and local level to make smokers aware of cessation methods, their basic principles and success rates, and the availability of local services.

— Encouragement of the training of all doctors and other relevant health professionals in the clinical practice of delivering smoking cessation interventions.

— Application of strong incentives and/or contractual drivers to implement evidence-based clinical cessation practice guidelines in routine primary and secondary medical care, dentistry and other health care provision to ensure that:

— Smoking status is ascertained and brief advice to quit delivered at all clinical consultations.

— All smokers who are motivated to quit are provided with the highest level of cessation support they are willing to accept, without delay.

— All smokers making quit attempts are followed up, and encouraged to try again if they fail.

— Provide the necessary funding resources to ensure that staff are trained and appropriate services are available for all smokers ready to try to quit.

3. Minimise uptake of smoking

Most smokers start to smoke in their teenage years, and all of the available evidence indicates that young people are less likely to experiment with and/or persist with smoking if smoking is perceived in society as an undesirable and/or unacceptable behaviour.

Therefore the above measures to denormalise smoking, and encourage cessation in adults, are also likely to have a substantial effect on the uptake of smoking and should be the first priority in preventing smoking in young people.

Additional policies that are likely to be effective include:

— Protecting children and young people from exposure to positive smoking role models, brand placement or other incentives to smoke in feature films by making these characteristics criteria for 18 classification in all new films.

— Applying a similar guideline to all new TV programmes in relation to transmission before or after the 9 pm watershed.

— Implement fully smokefree policies in all schools and colleges.

— Providing cessation services at school for young smokers.

Consideration should also be given to tightening controls at the point of sale of cigarettes:

— Requiring proof of age at point of sale for all purchasers who look under 25, and impose severe penalties on retailers who do not comply.

— Effective policing of point of sale regulations, backed up by a strong likelihood of severe penalties for individuals supplying cigarettes to underage smokers by whatever means (such as responsibility for vending machines).

— Licensing of tobacco retailers to provide the opportunity to withdraw licences from those allowing underage sales.

4. Encourage the use of safer sources of nicotine

Medicinal nicotine products are safe and should be strongly encouraged as an alternative regular source of nicotine. Some smokeless tobacco products (such as snus, which is widely used in Sweden) can also provide nicotine in a formulation that is a proven acceptable alternative to cigarettes for many smokers, and although more harmful than medicinal nicotine is much less harmful than cigarettes. The following policies are therefore likely to reduce significantly the harm caused by nicotine addiction:

— Encourage switching from smoked tobacco to medicinal nicotine, by:

— Promotion of medicinal nicotine as an alternative regular source of nicotine, rather than a cessation product.

— Packaging and promotion of medicinal nicotine in daily packs, to compete directly with cigarettes at the point of sale.

— Pricing of medicinal nicotine to give strong market advantage relative to smoked tobacco.

— Providing the necessary assurances and commercial confidence for manufacturers to invest heavily in the development of new and more effective medicinal nicotine products.

— Regulation of selected smokeless tobacco products to provide an interim alternative nicotine source to smoked tobacco and medicinal nicotine:

— Define safety standards for a limited range of smokeless products to be introduced as a social experiment, initially limited in test region(s) of the UK.

— Permit promotion of smokeless products to existing smokers under strict controls.

— Regulate and monitor the promotion and sale of smokeless products.

— Ensure that pricing of products is positioned between that of cigarettes and medicinal nicotine.

— Apply the same age restrictions on sale of smokeless products as cigarettes.

— Aim to phase out the use of smokeless products as and when this can be achieved without significant switching back to smoked tobacco.

5. Other supporting policy

The following are all areas important to the support and implementation of effective measures to reduce smoking:

Monitoring smoking behaviour:

Smuggling:

Protecting children:

National floor standards for protection against passive smoke:

Cross-departmental coordination of tobacco policy in government:

6. Establish a nicotine regulation authority

The above measures need coordinated supervision and monitoring if they are to be successful. Smoked tobacco products are extremely dangerous but are currently exempt from food, drug and consumer protection legislation; medicinal nicotine is extremely safe but is subject to tight medicines control legislation; smokeless products are much safer than cigarettes but are prohibited on health grounds. We suggest that the regulation of all nicotine products is brought under the control of a single authority with a remit and budget to:

— Take responsibility for all aspects of nicotine use in the UK.

— Implement and monitor the progress of all of the above policy initiatives.

— Adapt and respond to new developments and maximise the speed and effectiveness of new implementation.

— Establish standards for novel nicotine products.

— Co-ordinate the actions of the various government departments relevant to implementing the above policy.

— In particular, monitor the impact of opening the market to medicinal and approved smokeless products, and deal with any inconsistencies and unforeseen adverse impacts.

— Control and supervise marketing activities of tobacco companies.

— Commission research to address areas of uncertainty in established practice, new developments in practice, and in policy response.

IMPORTANCE OF BALANCING CESSATION AND HARM REDUCTION POLICY

— Smoking prevalence in the UK is currently about 26%, and is falling by about 0.4% per year.

— At this rate therefore, even if sustained, it will take 65 years to eradicate smoking from the UK.

— We suggest that with strong policy implementation it may be possible to increase cessation to achieve a 1% year-on-year reduction in prevalence in the shorter term, possibly more when adult prevalence trends start to translate into a reduction in uptake of smoking by young people.

— However, in the longer term this rate may not be sustainable, as the remaining population of smokers increasingly comprises those who find it especially difficult to quit.

— Hence it is important to begin to address the needs of this group early, by encouraging alternative nicotine use.

— We would suggest a target of achieving a similar rate of switching to alternative nicotine sources to that of complete cessation.

— The combined effect of these measures would then be to reduce smoking prevalence by up to two percentage points per year.

— On this model, achieving a smokefree society in the UK over a 20 year period is a challenging but achievable and realistic option.

OVERWEIGHT AND OBESITY

LONG TERM OBJECTIVE

To achieve a leaner, fitter and healthier nation and in this way reduce the prevalence of obesity in England/UK to less than 10% of the adult population and less than 5% of children and younger people.

MEDIUM TERM OBJECTIVE

To enable people of every age, and from every social background, to make informed choices about their eating and to become more physically active by better information, education and health promotion and through an environment that encourages activity.

What is the context of these objectives?

1. The size of the problem

Obesity is a disorder in which excess body fat has accumulated to an extent that health may be adversely affected.

Overweight and obesity are now so common among the world's population that they are beginning to replace under-nutrition and infectious diseases as the most significant contributors to ill health. The National Audit Office estimated for England that each year 30,000 excess deaths result from obesity, constituting 6% of all deaths. Moreover, many of these people die prematurely (National Audit Office Tackling obesity in England, 2001). However, despite the compelling evidence, many people, including doctors, continue to consider obesity as a self-inflicted condition of little medical significance.

There has been a rapid increase in the prevalence of overweight and obesity in all age groups across the UK over the last 20 years. For example, according to the latest Health Survey for England ( Joint Health Surveys Unit, 2002), between 1993 and 2002 the proportion of overweight and obese adults rose from 62% to 70% among men, and from 56% to 63% among women. So, over two-thirds of men and nearly two-thirds of women were either overweight or obese in 2002. The proportion who were categorised as obese increased from 13% of men in 1993 to 22% in 2002, and from 16% of women in 1993 to 23% in 2002. Obesity now affects over one in five adults in the UK.

Overweight young people have a 50% chance of being overweight adults, and children of overweight parents have twice the risk of being overweight compared to those with healthy weight parents. Obese 10- to 14-year-olds with at least one obese parent have a 79% chance of becoming obese adults (Whitaker et al Predicting obesity in young adulthood from childhood and parental obesity, New England Journal of Medicine, 1997). Furthermore, parental obesity more than doubles the risk of adult obesity in obese and non-obese children under 10 years.

If current trends continue, at least one-third of adults, one-fifth of boys and one-third of girls will be obese by 2020. These forward projections from existing data are conservative. If the rapid acceleration in childhood obesity in the last decade is taken into account, the predicted prevalence in children for 2020 will be in excess of 50%.

2. Health consequences

The health consequences of overweight and obesity are wide-ranging and serious, from type 2 diabetes, to the risk of coronary heart disease. At present, overweight and obesity may be more common in older age groups but the increase in the proportion of overweight and obese children is of major medical concern. The medical complications from overweight and obesity may become evident throughout life but are likely to occur much earlier because of the increasing fatness of children and young people. As well as exacerbating many health problems, increasing degrees of fatness shorten life.

3. Implications for health policy

To prevent obesity, the nation has to consume less energy and be more physically active. Most people, especially those prone to overweight, are well aware of these basic principles but, for various reasons, find it difficult to follow them. The challenge, in tipping the balance towards a trimmer and slimmer nation, is to help people overcome the many barriers to a healthier lifestyle.

4. Target groups

Although everyone needs to watch their weight, the national programme to tackle obesity is likely to be more effective if initiatives are targeted at those individuals, families and communities most prone to overweight, or for whom being overweight poses a higher risk to health. National and local initiatives should therefore target the following three priority groups, with particular attention to individuals, families and communities who may be disadvantaged in terms of age, gender, income, language, culture, ethnicity, ability/disability, or geographical location:

— All children and young people: healthy eating and an active lifestyle should be promoted to prevent the onset of overweight and to develop healthy habits for life.

— Children and young people who are overweight or obese: weight control should be promoted and the risks associated with overweight andobesity reduced. Priority should be given to those for whom obesity would confer extra risk of ill health (eg children with diabetes, or musculoskeletal problems), and to those suffering adverse consequences (eg bullying and low self-esteem).

— Adults with a tendency to become overweight or obese: weight control should be promoted and the risks associated with over weight and obesity reduced. Priority should be given to those at particular risk of obesity (eg through a family predisposition, pregnant women), or for whom obesity would confer extra risk of ill health (eg people with high blood pressure, diabetes, depression, musculoskeletal problems).

What policies are available?

In our report "Storing up problems: the medical case for a slimmer nation" (Royal College of Physicians, 2004), the College made the following policy recommendations:

— A cross-governmental task force should be established at Cabinet level to develop national strategies for tackling the threat from overweight and obesity, and to oversee the implementation of these strategies.

— Government should mount a sustained public education campaign to improve people's understanding of the benefits of healthy-eating and active living, and to motivate people to eat a healthier diet and adopt a more active lifestyle.

— New standards in nutritional content, food labeling and food marketing and promotion should be agreed jointly by the food industry and the Food Standards Agency. Incentives to encourage the production, promotion and sale of healthier foods should be introduced.

— Population-wide initiatives should be implemented at local level to tackle obesity. Public services should take the lead by promoting healthy eating and increased physical activity in public places and institutions, such as schools and hospitals.

— The prevention and management of overweight and obesity should be included in all NHS policies and clinical care strategies. Appropriate training programmes for doctors, nurses and other health professionals should be established.

— There should be further funded research to improve understanding of the societal and cultural factors behind the epidemic of overweight and obesity, and the development and implementation of effective prevention and treatments.

What should UK policy be on obesity?

1. National level co-ordination

There is evidence from around the world that centrally coordinated, multi-agency, strategic approaches to tackling obesity are more likely to achieve substantial and sustained results. Such approaches are often contained within broader health improvement strategies.

In England, the Government White Paper on health improvement, "Saving lives: our healthier nation" (1999), sets targets for reducing the impact of such major killers as coronary heart disease (CHD), strokes and cancers. Saving lives proposes action at three levels: individual, community and government (national).

RCP Patient and Carer Network

Central and local government should take a more active role in making it easier for people to access better community spaces, gyms, exercise activities, local authorities, town and country planners etc, could support small corner shops, rural businesses, to stay open to provide employment, acessibility etc. They could be encouraged by being given incentives to sell fresh fruit and vegetables, healthy food and snacks, therefore families would be given the opportunity to walk to shops/or cycle instead of using cars, buses etc to shop further from their homes.

Government has also developed diseased-focused plans to prevent and treat major diseases such as CHD, stroke, diabetes and cancer. For example, there are national service frameworks (NSFs) to tackle cancers, mental health, CHD, diabetes, health problems in older people (including stroke and falls), and children's health. Each of these will have a major impact on overweight/obesity in various ways, and the CHD NSF specifies reducing obesity as a designated priority with stated objectives and milestones.

And there are specific plans to improve the national diet or increase physical activity and sport such as England's "Game plan" and its recent physical activity strategy and food and health action plan. The UK-wide Food Standards Agency (FSA) is also doing much to promote healthy eating by encouraging the food industry to improve the nutritional quality of processed and convenience foods, to promote healthier alternatives and to develop simple nutritional labeling

To succeed in tackling the time bomb of obesity the Government needs a cross-governmental, "joined-up", high-level strategy which gathers together all these elements and welds them into a coherent, whole-system approach to the prevention and treatment of overweight and obesity.

2. Public education and social marketing

In the developed world, there are a number of national public education campaigns that have succeeded in raising awareness of the issues and promoting healthier eating and more active living, the most notable example being Finland's North Karelia Project. Multimedia public education approaches have proved effective in reducing weight gain in two large-scale community-based programmes in the USA.

As part of its strategy, central government should mount a promotional campaign to motivate the public to eat a healthy, balanced diet and adopt a more active lifestyle. The campaign should be directed at everyone, whatever their background, but should particularly aim to engage children, young people, and people who are disadvantaged or from those ethnic groups at greatest risk from increasing fatness.

People's choice of food and drink depends greatly on such factors as price and availability, as well as flavour, quality, convenience and nutritional value. The food industry, from farm gate to consumer's plate, has a key role to play in determining what foods are consumed and in what quantity or balance.

The dominant force in this chain is likely to be the supermarkets, which can strongly influence primary producers as well as consumers. Ideally, consumers should be presented with a wide choice of foods from which they can select a healthy balance for the family table at prices the poorest can afford. Theoretically, the contents of the family shopping trolley should correspond to nationally recommended dietary intakes.

Much work is currently being undertaken in partnership with the food industry to try to shift consumer demand away from high fat, high sugar, high-calorie products, towards healthier alternatives. However, greater effort is needed to achieve a healthier national diet and, in particular, to increase consumption of fresh fruit and vegetables. This should go beyond simply engaging the food industry in initiatives, and should instead aim for joint working towards good practice as part of the food and advertising industries' corporate social responsibility.

As people become more aware of the health consequences of what they eat and drink, so it becomes increasingly important for them to have useful nutritional information about each food item. This should include guidance on calorie content. However, it is essential that this is given in an easily understandable form, such as simple symbols indicating "high', "medium" and "low" calorie content. As far as possible, this should be in accordance with the latest European Union nutritional labeling proposals.

3. Promoting "active transport"

Any national strategy must contain a strong element promoting "active transport", ie discouraging the unnecessary use of cars, and encouraging walking and cycling. This might involve initiatives regarding town planning, building specifications, road taxation, VAT on bikes, etc. Safety of walkers and cyclists is a key issue. The need for policies, which promote and support active transport has already been recognised by the Government.

4. Promoting leisure-time physical activity

Much is already being done to promote leisure-time physical activity and sport. All four UK countries have well-funded non-governmental organisations (NGOs) which promote such sport and leisure activities. All four have comprehensive strategies in place, with clearly identified priority target groups. However, there is still much to be done, particularly in terms of joining up with local strategic partnerships for health and well-being. A key gap is the lack of strong and effective links between the leisure and health sectors.

RCP Patient and Carer Network suggestions

— Having shorter journeys to work.

— More time should be allotted in school to health and home.

— Free supplies of fruit for all school-aged chidren to support the five a day campaign.

— Support for workplaces to provide sporting facilities, reduced entrance costs to sports clubs, teams etc.

— Provide greatly-reduced entrance costs to sports clubs etc for unwaged members of the public.

— Encourage canteens in schools, collgees, universities, workplaces, all public places to provide healthy choices on their menus.

— Access to fresh food—out of town supermarkets may deprive the poor and elderly access and generate traffic/transport issues and means fewer people walking to shops (same for argument for locating pharmacies in supermarkets, restricts choice for those without access).

— Supporting services in rural areas ie sports clubs, aimed at different ages groups, regular bus services providing regular access to these venues in nearby towns to help alleviate social isolation, causing ill health etc.

— Encourage workplaces to introduce flexible working times—to allow parents to walk their children to school before commencing work. Central government to support and encourage more "walk to school" initiatives, safer cycling routes etc.

5. Promoting healthy schools

There is evidence to support a multifaceted approach to promoting healthy eating and physical activity in the schools setting, including: curricular and non-curricular education; healthy food and drink choices in school meals, tuckshops and vending machines; and sport, active pursuits and active travel to and from school.

For many years, school catering suffered from inadequate budgets and an absence of statutory nutritional standards. In 2001, national nutritional standards were re-introduced and catering budgets were made the responsibility of school governors. Hopefully, these changes will result in healthier choices for all schoolchildren. In particular, there should always be an attractive choice of fresh fruit on offer in school dining rooms.

In England, the National School Fruit Scheme, offering every child in England aged four to six a free piece of fruit each school day, has been successfully piloted and will be fully operational nationwide from 2004. The Government has also recently launched its "Food in schools" programme, jointly run by the Department of Health and Department for Education and Skills, which will involve over 500 schools in eight pilot projects around the country, looking at a range of initiatives from breakfast clubs and lunchboxes to healthier vending machines, fruit tuckshops, and after-school cookery classes.

Pressure on the school curriculum has been blamed for the gradual erosion of teaching time devoted to sports, active games and physical education. There has also been a trend toward selling off school playing fields in order to help balance hard-pressed education budgets. These issues are being actively addressed and the trends reversed. There is now a minimum standard of two hours of moderate physical activity in school time per week. Very large capital sums, from such sources as the New Opportunities Fund, are being invested in schools' sport and physical education facilities and equipment, focusing on the more deprived areas of the country.

In England, the National Healthy School Standard aims to encourage schools to develop a "whole school" approach to health and to consider diet and physical activity (along with sex and relationships, drugs and alcohol, tobacco and citizenship) in all aspects of school life. It is part of the Healthy Schools Programme, led jointly by the Department for Education and Skills and the Department of Health. Similar initiatives exist in other UK countries.

However, it is up to the individual school to decide its Healthy School priorities, and in many cases education in sex and relationships, drugs and alcohol takes precedence over attention to diet and physical activity.

One aspect of the whole school approach is to ensure that healthy eating messages are consistent across the classroom, dining room, tuckshop and vending machine. The tuckshop and vending machine, in particular, should not promote sugary or fatty snacks or sugared drinks. School governors should consider banning these items from the tuckshop or vending machine. At the same time, they should ensure the easy availability of plain drinking water. In Scotland, the provision of water and fruit juice in school vending machines is now mandatory and advertisements on the front of the machines promoting sugar-sweetened drinks and fatty or sugary snacks are banned. It is important that these school-based initiatives are sustained and built upon, involving parents and local communities.

6. NHS priorities, planning and performance

Recent NHS priorities and planning guidance continues to focus on health services and pays scant attention to tackling obesity or promoting healthy eating and active living. Any references to these aspects tend to be inferred in longer-term targets concerning CHD and cancer, with an emphasis on adults. The urgency of the problem among children and young people is barely acknowledged. It is most important that the prevention and management of overweight and obesity, prioritising children and young people, be given greater prominence in future priority-setting and planning for the NHS and social care.

With regard to adults, an important opportunity now exists with the implementation of the new General Medical Services (GMS) contract. The contract's Quality and Outcomes Framework is designed to raise organisational and clinical standards in primary care, with an emphasis on teamworking and nurse-led chronic disease management. Within it is a requirement to record accurate data in a standardised electronic format. This should greatly improve risk management of CHD, stroke, hypertension and diabetes, including the risks associated with overweight and obesity. Along with other initiatives such as the Expert Patients Programme and the Electronic Patient Record, this is expected to contribute greatly to an improved service for managing overweight/obesity, and for monitoring the implementation and effectiveness of programmes to prevent and treat obesity.

However, there remains a lack of coordination in terms of workforce planning. As more and more overweight patients are assessed as being at risk of cardiovascular disease or diabetes, so this will put a greater strain on local community dietitians and exercise referral services. It is essential that workforce planners factor these trends into their calculations, and provide for extra community dietitians and physical activity coordinators as necessary. All NHS trusts should ensure that the management of overweight and obesity is integrated into all relevant clinical programmes.

The NHS Expert Patient's Programme should be extended to include sessions for children and young people with a more positive attitude to good health and prevention. This would make a contribution to reducing the number of obese and overweight children and young people.

RCP Patient and Carer Network

7. Prevention programmes at local level

Sustained change can only be brought about by working in a "whole system" way across the various sectors locally. Local strategic partnerships (or local community planning partnerships or equivalent) should be urged to develop local action plans to tackle obesity as a priority within their community strategy to promote well-being in their population. In England, a requirement along these lines is included in the Coronary Heart Disease NSF. The Faculty of Public Health has also published a toolkit to help local teams develop and implement action plans to tackle obesity.

Action to prevent obesity at local level will require a co-ordinated approach involving a range of partner organisations, notably:

— Community services, such as health visiting and community child health services, eg school nursing.

— Schools and local education authorities.

— Leisure services.

— Local authority planning departments and parks departments.

— Police and community safety partnerships.

— Primary care organisations and general practices.

— Hospitals and community health services.

— Community groups and voluntary bodies.

— Local food retailers and caterers.

— Local employers.

— Local media.

A practical framework for local programmes could be that offered by the so-called "healthy settings" approach, which focuses interventions in a number of key settings to develop a co-ordinated programme for obesity prevention. There are many possible settings to develop: from home to hospital, from park to prison, and from community group to club or pub. Each provides a particular opportunity to influence people's eating, drinking and physical activity habits. A simple range of settings for preventing obesity might include:

— home and pre-school;

— school;

— workplace;

— community group;

— leisure facility;

— retail outlet;

— media;

— GP surgery, health centre or clinic; and

— wider population.

RCP Patient and Carer Network

"There exists a large evidence base on major inequalities . . . The major gap is the inability of agencies and areas to work together for the benefit of individuals and families."

ALCOHOL

Long-term objective

The long-term objective of public health policy in relation to alcohol use should be to minimise the damage to health through its misuse.

What is the context for this objective?

— Alcohol consumption has more than doubled in the UK since 1960, and is rising at a time when it is falling in many parts of continental Europe, such as France and Italy.

— The rise in consumption closely mirrors affordability.

— Almost one in three adult men and nearly one in five women now exceed the recommended guidelines of 21 and 14 units per week respectively.

— Alcohol is second only to tobacco as the main cause of preventable premature death in the UK.

— There has been a three- to 10-fold increase in deaths from cirrhosis in the last 35 years.

— Many of these people are not dependent on alcohol and can stop drinking when damage to health becomes apparent, but often this is too late.

— The increase in both drinking and harm is most marked in younger age groups.

— The cost to the NHS is about £1.7 billion.

— Alcohol is responsible for about a third of Accident and Emergency (A&E) attendances, rising to 70% during the night, and about 150,000 hospital admissions each year.

per capita

It could be argued that policy in the alcohol arena has been set by the Government strategy, launched through the Cabinet Office in March this year (Alcohol Harm Reduction Strategy for England, Cabinet Office, 2004). While we welcome this strategy, we believe it does not go nearly far enough in the field of health, both in disease prevention and treatment. For instance:

— There is undue dependence on voluntary action by the drinks industry.

— There is no clear plan with proper outcome targets for any partnership with industry.

— There are calls for pilot schemes for brief interventions when the evidence from pilot studies is already available.

— There is undue emphasis on auditing existing alcohol treatment services rather than properly funding and extending them.

— The strengths, such as the emphasis on earlier detection and prevention of harm, are not backed up by funding.

— The opportunity to use the new GP contract to develop primary care targets has been missed.

— The opportunities to use presentations to A&E departments and acute hospital wards are not developed.

— There is no requirement on acute hospital trusts or PCTs to give development of a coherent alcohol strategy any priority and no targets to drive progress.

— Little or no attention is given the measures that are of proven benefit in reducing harm—price and access. While the Government fears electoral repercussions of such levers, it misses an opportunity to engage the population in proper and responsible debate.

What policy measures are available?

These fall into the categories of education, research, availability of alcohol, marketing, enforcement, detection of hazardous drinking and treatment.

Education

— General Public.

— Product labelling.

— Health care workers (PCT, acute hospital, med students and nurses).

Research

— Proper funding streams for basic and health service research.

Availability

— Price.

— Numbers of outlets.

— Licensing hours.

— Cheap imports.

— Age controls.

Marketing

— Advertising.

— Promotional approaches (students, happy hours).

Enforcement

— Drink-driving limits.

— Under-age purchase and drinking.

Detection of Hazardous Drinking Patterns

— GP well man/woman clinics.

— Occupational health screening.

— Alcohol-related attendances—eg A&E departments.

— Coincidental attendances to primary or secondary care.

Treatment facilities for alcohol dependence

What should UK policy be on alcohol?

1. Making the polluter pay

The issue of government levers and, in particular taxes, and how they might be used to influence key areas is explored in "Securing Good Health for the Whole Population" (Wanless February 2004). We particularly welcome the concept as outlined in para 8.28 that "the product or unhealthy ingredient be taxed". The government alcohol strategy itself highlights that the alcohol industry must share responsibility for tackling the harm associated with alcohol misuse (Chapter 7, Pages 75-80, Alcohol Harm Reduction Strategy for England).

The evidence drawn together by the Cabinet Office Strategy Unit to inform policy includes the fact that 25% of the adult population of the UK are currently drinking alcohol at levels which may cause harm (interim analytical report p 142), and that 2.9 million people show evidence of alcohol dependence (interim rep p 38). In the final strategy (p 18, fig 2.4) the Government estimates direct costs to the NHS at £1.4-1.7 billion and to society from crime and in the workplace at up to £7.3 billion and £6.4 billion respectively. The damage to children and families is beyond quantitation.

At present the alcohol industry contributes nothing to these costs yet has an annual turnover in excess of £30 billion. This is fundamentally wrong. The "polluter" should pay a proportion of the cost, and we propose that a levy of the turnover of the alcohol industry should go towards remedying some of the health and social harm caused by alcohol. The government has accepted in part this argument and has called for a voluntary donation by the industry to an independent fund designed to tackle alcohol related harm, but has set no guidelines for the level of this donation nor made specific proposals as to how the funding should be used.

We propose a contribution by the alcohol industry of 1% of turnover—representing a tiny fraction to both consumers and to the industry as a whole but with the potential to counteract some of the immense harm caused by alcohol to society in England. The funds would amount to less than 20% of the costs to the NHS, but set against the funds currently available for education, prevention and treatment of alcohol related harm could make a real difference. Government estimates that at present less than £100 million is spent on specialist alcohol services and education—with less than £24 million of this provided via the NHS and the remainder by the voluntary sector (interim analytical report p 47).

This funding must be administered by an independent body to promote significant amelioration of alcohol related health and social costs. Priorities would include: acting as a catalyst for the development and identification of good practice; start up funding to build the capacity of specialist services; education and training of health workers; targeting information and promoting culture change.

We suggest that the alcohol industry be given an opportunity to contribute this 1% levy voluntarily, but agree with government that additional steps including legislation should be taken after a defined interval if the industry does not take on its share of responsibility under voluntary arrangements.

2. Establishing a coherent strategy for the identification and management of harmful and hazardous drinkers presenting to hospital services

In view of the magnitude of the burden placed by alcohol on hospital services (estimated at 2-12% of total NHS expenditure on hospitals) it is vital that these services have in place appropriate strategies for the early identification and management of harmful and hazardous drinkers. These include both the initial management of alcohol withdrawal in dependent patients, as well as management strategies directed at abnormal drinking behaviour that causes admission or, in the case of coincidental hazardous drinkers, that may lead to alcohol-related admissions in the future. Strategic Health Authorities would seem ideally placed to co-ordinate the development of such a strategy since this will include the activities of acute hospital trusts, as well as mental health trusts.

Targets and time-scales

— Each Strategic Health Authority to have in place a coherent strategy for the detection and management of harmful and hazardous drinkers presenting to hospitals within its remit—strategy in place by the end of 2005.

— The appointment of a national lead ("Tsar") to help change the culture in secondary care regarding the attitude of health care workers to patients with alcohol related problems—achieved by end of 2005.

— Each Strategic Health Authority to appoint a steering group consisting of a senior member of medical staff and nursing staff, a senior psychiatric colleague with an interest in the management of alcohol problems, along with senior managerial personnel to devise and implement the alcohol strategy—achieved by end of 2005.

— Each Acute Trust to have in place at least one dedicated alcohol health worker responsible for:

(a) the implementation of screening strategies;

(b) detoxification of dependent drinkers;

(d) referral of patients for ongoing support where necessary;

(e) provision of links with liaison/specialist alcohol psychiatry; and

(f) education for other health care workers in the Trust.

These targets should be achieved by end 2006.

3. Reduction of Alcohol Related Illnesses

There is a clear relationship between per capita alcohol consumption and the prevalence of illnesses/diseases where alcohol is a direct cause. These diseases include those where alcohol is a necessary and sufficient cause of a presenting conditions, such as acute alcohol intoxication and alcoholic liver disease, and also cases where alcohol is a sufficient but not necessary cause, for example pancreatitis and epileptic seizures. Based on the experience in other countries (eg Spain and Canada) we believe that any "sensible" national alcohol strategy should have at its core, an aim to reduce per capita consumption, and that an achievable target for this aim should be a reduction in diseases where alcohol is a direct cause. In diseases where alcohol is a sufficient but not necessary cause, the target should be to reduce the "attributable" proportion of that disease related to alcohol. Specific targets should include:

— Reduction in admissions due to acute intoxication.

— Reduction in the death rate from alcoholic liver disease (see increase documented in Chief Medical Officer of England's report, 2000).

— Reduction in admissions to accident and emergency departments directly or indirectly related to alcohol excess.

— Reduction in suicide rate.

— Reduction in road casualties due to drink driving. These fell steadily from 1990 (20,400) to 14,980 in 1993 but they have shown a steady increase since then reaching 20,140 in 2002.

These targets should be achievable by 2010.

4. Enhancement of Primary Care Services

The new General Medical Services contract could allow for Locally Enhanced Services to support the management of moderate alcohol problems in general practice. The status of a National Enhanced Service would do much to promote a more robust approach in primary care.

SEXUAL HEALTH

LONG-TERM OBJECTIVES

To provide a safe environment in which the population can enjoy the sexual behaviour of their choice, resulting in low levels of sexually transmitted diseases and unwanted pregnancies comparable to or better than any in western Europe.

MEDIUM-TERM OBJECTIVES

— To ensure all children have high quality effective sex and relationship education.

— Provide adequate education on sexual health to all relevant health care and educational personnel at undergraduate and postgraduate levels.

— Raise the age of at which coitarche occurs.

— Increase the number of persons using condoms at first intercourse (coitarche), on partner change, oral sex by gay men.

— Reduce the number of partner changes.

— Ensure appropriate access to high quality integrated sexual health services.

— Implement screening programmes for C trachomatis for all at risk groups for women and men.

— Implement vaccine programmes for hepatitis B and human papillomavirus.

— Protect vulnerable persons from sexual abuse.

— Promote an environment in which sexual health issues can be openly discussed without fear, embarrassment or prejudice.

WHAT IS THE CONTEXT OF THESE OBJECTIVES?

1. The size of the problem:

— Falling age at coitarche.

— Unacceptably high numbers of persons have unprotected sexual intercourse at coitarche and with non regular partners.

— Increasing number of partners.

— Increasing number of persons having same sex contact.

— Among highest levels of teenage pregnancies in Europe.

— High rate of termination of pregnancy.

— Increasing number of serious sexually transmitted infections (STIs) eg chlamydia trachomatis, syphilis and HIV. Between 1992 and 2002 in England, Wales and Northern Ireland reports of chlamydia rose by 139%, gonorrhoea 106% and syphilis 870%. The largest increase was in the under 25 year old age group (Health Protection Agency).

— Mild to severe erectile dysfunction (ED) affects 52% of men between the ages of 40 and 70 with 10% being severely affected.

2. Factors affecting sexual behaviour

There are many influences on sexual behaviour and it is only possible to focus on the major ones which may be amenable to modification. Change can be difficult once a pattern of sexual behaviour has been established.

— The family is the ideal place for young persons to receive sex and relationship education (SRE) but is often not able to deliver the necessary knowledge and skills.

— Education has an important bearing on sexual behaviour and risk avoidance.

— Peer group pressure can result in both positive and negative influences.

— Prejudice can lead to fear, embarrassment and covert sexual behaviour.

— Religions commonly set only one standard of behaviour.

— Cultural influence can lead to differing patterns of sexual behaviour.

— Media/advertising has become highly sexualised.

— Role models can influence sexual attitudes.

— Alcohol/drugs lead to disinhibition and risk taking.

— Sexuality can influence behaviour patterns and vulnerability.

3. Services available to deal with sexual health

Specialist

— Family planning services are chronically short of doctors and nurses and not funded to carry out infection screens.

— Genito Urinary Medicine (GUM) clinics are overwhelmed with ever increasing numbers of new patients and demands for sexual health checks.

— Psychosexual services are totally inadequate.

— Termination of pregnancy services have patchy availability throughout the country.

Non Specialist

— Primary care medical and nursing services have had inconsistent involvement with sexual health issues often not regarding them as priorities.

Schools and further education colleges

— Whilst good SRE programmes exist they may start too late or be inhibited by Boards of Governors, parental or religious pressures.

— Youth services have increasingly become involved with sexual health and should be utilised especially for peer group education.

RCP Patient and Carer Network

"Start sex education early, stop being so prudish."

4. Implications for health policy

Policy measures which could influence harm reduction are:

— Raise age at coitarche.

— Reduction of partner change rate.

— Use of barrier protection.

— Effective use of contraceptive services.

— Effective use of contraception.

— Effective use of an access to sexual health services.

— Improve information and education at all levels in society.

— Implementation of effective vaccine programmes.

WHAT POLICIES ARE AVAILABLE?

Government has made a number of initiatives (ie National Strategy for Sexual Health and HIV, Department of Health, 2001) which if fully implemented could make a very significant contribution to sexual health. Policies tailored to maximise damage limitation are:

— Providing access to high quality integrated services.

— The promotion of safer sexual practices.

— Ensuring SRE for all young persons.

— Influencing the media to improve the sexual health message.

— Conducting programmes of public information campaigns.

— Conducting relevant research into sexual behaviour and the effectiveness of SRE.

— Engaging those commercial interests that influence sexual behaviour eg alcohol, entertainment.

— Implementation of appropriate screening programmes.

LIKELY TIME EFFECTS OF IMPROVED POLICY APPROACHES

The time course to show effects of policies is unpredictable but improvement should be monitored with 5 yearly target setting.

1. Policies that reduce risk taking behaviour

— Increase of knowledge and relationship skills.

— Substantial increase in use of effective barrier protection and contraception.

— Increasing age at onset of sexual activity.

— Substantial reduction in partner exchange rates.

— Control of alcohol and drug misuse.

2. Policies that promote society/personal responsibility

— Involvement of schools, religions, special interest groups in realistic goals of SRE.

— Involvement of the media in shared sexual health goals.

— Substantial changes in role models sexual behaviour.

— Involvement of the alcohol industry in social marketing.

3. Policies that reduce harm caused by sexual ill health

— Increasing age at onset of sexual activity.

— Reduction in poverty and loss of opportunity attendant to teenage/unwanted pregnancy.

— Substantial reduction in major complications such as sub fertility, ectopic pregnancy, genital tract cancers over 10-20 years.

— Substantial reduction in serious morbidity and mortality secondary to HIV disease 10-20 years.

— Substantial reduction in need for expensive antiretroviral therapies (ART) 10-20 years.

— Substantial reduction of psychosexual problems secondary to relationship breakdowns.

WHAT SHOULD UK POLICIES BE ON SEXUAL HEALTH?

1. Reduce the drivers to unsafe sexual behaviour

— Promote personal responsibility for own and partners sexual health through SRE.

— Reduce prejudice, fear and embarrassment associated with sexual health issues especially STIs/HIV through education, media, information campaigns.

— Agree standards for media's portrayal of sexual behaviour and health including incorporation of topical sexual health issues into soaps, dramas, etc.

— Normalise sexual behaviour as a serious public health issue.

— Strict enforcement of alcohol misuse policies especially underage drinking.

— Monitor use of other drugs and their relationship to unsafe sexual behaviour.

— Engage with influential sections of society—special interest groups etc to set common realistic goals for achievable targets.

2. Maximise the uptake of sexual health seeking behaviour

— Promote peer group education, which has been shown to be the most effective way of influencing young persons' sexual behaviour.

— A programme of sexual health education campaigns on issues such as the impact of unplanned/teenage parenthood in terms of poverty, reduction in opportunity etc.

— Use advertising and education to inform people about the risks of sexual ill health in their lives and empower them to seek appropriate help and advice.

— Educate the public on the dangers of asymptomatic STIs especially C trachomatis and HIV. Promoting the uptake of specific screening programmes such as that currently being rolled out for C trachomatis.

— Target groups with particular sexual health problems/needs for information/harm reduction campaigns: gay men; Afro-Caribbeans, immigrants and their partners.

— Set targets for appropriate age for first sexual intercourse as well as condom usage at sexual intercourse and at partner change.

— Set targets for partner change reduction. This is a more powerful driver for reduction of certain STIs than the use of condoms.

— Provide high quality, easily accessible sexual health services.

— Promote innovative sites for delivery of sexual health services eg youth services.

— Provide resources to improve access to services. The GUM specialty has a target of 48 hour access for investigation and treatment, but waiting lists of several weeks are common. Delayed diagnosis is a factor in onward transmission of infection.

— Ensure confidentiality of services.

— Provide "tailored" services for groups with special needs eg young persons, immigrants, gay men, lesbian women and commercial sex workers.

3. Encourage the use of preventive measures

— Condoms reduce the risk of transmission of many STIs and unwanted pregnancies. They are given out free in GUM and family planning services but not by GPs or other health care providers.

— Industries providing alcohol have a recognised social responsibility on issues such as drunk driving. There are direct parallels as to impaired judgement leading to unsafe sex. These industries should include sexual health issues in their advertising; provide health information via posters etc and free condoms.

— The consequences of unwanted pregnancy both in social and health terms considerably outweigh the risk of chemical contraceptive usage. Persons identified as not using contraception adequate to their needs should have immediate access to integrated sexual health services.

— Use of condoms for oral sex is negligible in both heterosexual and gay communities. Epidemiological statistics show that unprotected oral sex is of particular concern as a driver of outbreaks of syphilis in the gay community. Vigorous campaigns need to be initiated to promote the use of condoms for oral sex with casual partners.

— Screening programmes for preventable STIs would lead to important reductions in prevalence of infection. In addition to the programme being initiated for CT in females, a programme needs to be devised for males.

— Hepatitis B is a serious sexually transmissible infection preventable by vaccination. Most at risk are gay men and partners of immigrants. In the USA all children are vaccinated against this disease. A similar campaign should be instigated in the UK.

4. Minimise the impact of sexual ill health

— Implement the House of Commons Select Committee report on sexual health (Report on Sexual Health, 2003) in particular, investment in high quality sexual health services.

— Prompt access to diagnosis and treatment of STIs/HIV is essential.

— Implement a vaccine policy against hepatitis B.

— Government needs to begin planning immediately for the possibility of safe and effective vaccination against human papillomaviruses. This will almost certainly be available within five years and will potentially make a major impact on incidence of cervical cancer and other genital tract cancers.

— Asymptomatic C trachomatis infection results in serious morbidity and onward transmission. Prompt implementation of screening programmes should be instituted.

— Ensure money going to services reaches its intended goal. Anecdotal evidence exists that recent allocations, of money for hard-pressed GUM services has not been passed on to the intended recipients.

— A recent publication by MedFASH on the establishment of managed patient networks for persons with HIV/AIDS and the forthcoming recommendations for STIs would be of great value in the management of these problems. But their implementation will require considerable investment on the part of Government.

— Ensure early access to TOP services throughout the country.

— Promote use of medical induction of TOPs.

— Postcoital contraception (PCC) services should be freely available seven days a week through pharmacies, primary care and specialist sexual health services. Ideally, persons seeking PCC, should at least be given information on locally available contraceptive services and be referred through electronic booking systems.

— There should be minimum standards of investigation and treatment available to all sexual health services. For example:

— Home therapies with podophyllotoxin/Imiquimod are under utilised. These save on clinic visits and provide private personal treatment for patients.

— Erectile dysfunction is a major cause of mental ill health and relationship difficulties. Services across the country are erratic and medical treatments are not widely available on NHS prescription. These issues need to be addressed perhaps through a NICE assessment.

— Access to relationship/sexual health counseling—which can prevent mental health problems and relationship breakdown—is currently inadequate. While sexual health advice is currently available through GUM clinics, access needs to widened through primary care, contraceptive services.

5. Establish effective networks of services

Government should consider taking sexual health services out of current funding arrangements through Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) where they are given low priroity. The establishment of a sexual health authority to oversee the organisation and energising of services should be considered.

— The National Sexual Health and HIV Strategy outlines a vision of well-trained levels of services in primary and secondary care. This needs to be implemented.

— Integration of sexual health services would greatly enhance their efficacy and effectiveness. Models of care do exist and should be emulated.

— Budget holders (SHAs/PCTs) must ensure appropriate leads and finance are available. Currently, no PCTs have sexual health leads and the issue is low down on their list of priorities. There is evidence that money provided to GUM has not been passed on.

— Common protocols should be established for the management and investigation of STIs.

— Access to information and education through the internet, email, text and telephone communication would greatly enhance knowledge and access.

— Confidentiality remains a major issue for those accessing sexual health services. These concerns need to be addressed, particularly with the introduction of a computerised common health record.

6. Promote education on sexual health for professionals and community

— Education of health care professionals is currently inadequate to deliver a uniformly high standard of services.

— Undergraduate/postgraduate curriculums for all relevant professions need to have components on sexual health education.

— GPs with special interest (GPwSI) must have adequate training, supervision and governance.

— Instigate training of teachers as a core part of undergraduate curriculums with a postgraduate diploma.

— Every school should have at least one teacher to lead SRE.

— SRE should be made available for adults through further education authorities, night classes etc to prepare for relationships and parenting.

— Education for persons of influence ie religious leaders should be implemented.

— Establish multi religious/cultural forums to set common goals.

— Health promotion authority to promote sexual health advertising/media campaigns.

7. Promotion of research

Many disparate strands of variable quality research are currently undertaken. A sexual health authority could promote and quality ensure research in such fields as:

— Effective SRE.

— Vaccination against infections ie HIV, herpes simplex virus and C trachomatis.

— The effectiveness of health advice.

— Trends in sexual behaviour. The NATSALS survey—occurring at 10-year intervals—has provided invaluable information.

— The effectiveness of preventive measures.

— Investment in IT could enable information gathered every day at GUM clinics to become a national data resource indicating trends in sexual behaviour.

— Cohorts of young persons could be recruited for ongoing monitoring of trends in society allowing updating of goals and targets.

— Vaginal microbicides would enable women to have greater control over prevention of infection. This may be particularly important in ethnic groups.

— Drivers for and effects of sexual ill health in minority groups eg immigrants, ethnic minorities and gay men.

HEALTH INEQUALITIES

We welcome the fact that the Government now has in place a cross-government plan for reducing the socio-economic divide and tackling health inequalities: "Tackling health inequalities: a programme of action" (Department of Health, 2003); clear national targets for reducing inequality in health outcomes; as well as a number of linked initiatives and strategies such as the Teenage Pregnancy Strategy; smoking cessation, reform of the Welfare Food Scheme; and the establishment of Sure Start.

Our concern is that the actions the Government is taking on reducing health inequalities be explicitly linked to public health policy. In this context we strongly endorse the analysis of the social determinants of health as described in "The Solid Facts," published by the WHO (1998), namely that:

— Health follows a social gradient.

— Stressful circumstances are damaging to health and may lead to premature death.

— A good start in life means supporting mothers and young children: The health impact of early development and education lasts a lifetime.

— Social exclusion: Life is short where its quality is poor. By causing hardship and resentment, poverty, social exclusion and discrimination cost lives.

— Work: Stress in the workplace increases the risk of disease. People who have more control over their work have better health.

— Unemployment: job security increases health, well-being and job satisfaction. High rates of unemployment cause more illness and premature death.

— Social support: Friendship, good social relations and strong supportive networks improve health at home, at work and in the community.

— Addiction: Individuals turn to alcohol, drugs and tobacco and suffer from their use, but use is influenced by the wider social setting.

— Food: Because global market forces control the food supply, healthy food is a political issue.

— Transport: Healthy transport means less driving and more walking and cycling, backed up by better public transport.

While it is clear that Government has recognised the impact on health generally of these wider social determinants, there is little evidence that they have been actively considered by Ministers in respect of public health.

OBESITY AND HEALTH INEQUALITIES: AN EXAMPLE

Taking the link between obesity and socio-economic status as an example, people living in households without an earner consume more calories than those living in households with one or more earners. Poorer households eat less fruit and vegetables, salad, wholemeal bread, wholegrain and high-fibre cereals and oily fish, and more white bread, full-fat milk, table sugar and processed meat products. Furthermore, poorer households in poorer communities are less likely to have access to healthy, affordable food and suitable recreational facilities. The main barriers to healthy eating and adequate physical activity for those on low income are as follows:

— Low income and debt.

— Inaccessibility of affordable healthy foods.

— Lack of facilities/skills/time to cook.

— Lack of accessible information on nutrition.

— Poor literacy and numeracy skills, affecting understanding of food labeling and nutritional information.

— Lack of access to affordable sports facilities.

— Poor urban environments.

— Lack of community safety.

— Sedentary lifestyles.

— Limited encouragement of exercise at school.

— Limited play facilities.

— Lack of safe places to play or exercise.

Addressing these barriers requires action on three broad fronts—environment, empowerment and encouragement—aimed at engendering a collective behaviour change. As regards obesity this plan of action would look as follows:

1. Environment

Creating an environment (physical, social and economic) which predisposes to healthy eating and active living. The purpose is to make the healthier choices the easier choices by removing barriers such as high cost or difficult access. This includes tackling inequities caused by exclusion, disadvantage or poverty. Examples:

— Free fruit in schools.

— Healthy school policies, eg healthy catering, fruit tuckshops, plentiful drinking water, breakfast clubs, after-school activities (including dance), and an absence of vending machines dispensing sugary drinks and fatty, sugary or salty snacks.

— Conveniently placed food outlets offering healthier choices at affordable prices, including food "co-ops" in which community groups purchase foods direct from growers or wholesale suppliers and sell at cost to people on low incomes.

— Agricultural policies and food subsidies that help to provide healthier choices at affordable prices.

— Safe walking and cycling routes to school and work.

— Town planning that discourages car use.

— Safe, accessible parks.

— Buildings designed to encourage stair use and discourage lift/escalator use.

— Bike racks and shower facilities in workplaces.

— Cheaper and easier access to leisure and sports facilities.

— Culturally sensitive exercise facilities (eg women-only swimming sessions).

— Media-created ethos that a healthy active lifestyle is "cool".

2. Empowerment

Giving people, particularly children and young people, knowledge and understanding of the benefits of healthy eating, active living and avoiding overweight, and the life skills to adopt healthy behaviours; boosting confidence and self-esteem, individually and collectively. This includes educating key opinion formers such as health professionals, schoolteachers and the media. Examples:

— Personal, social and health education (PSHE) work in schools.

— Teaching the principles of healthy eating and cooking skills.

— Physical education (PE), sports and other supervised physical activities in schools.

— Teaching citizenship and advocacy skills.

— Working with communities (eg minority ethnic groups or housing estate residents) to understand their needs for a healthier diet and more exercise, and to demand better access to fresh fruit and vegetables, a leisure centre etc.

— Health visitors working with new mothers and young families to support and encourage breastfeeding, healthy eating and healthy active play.

— Nutrition and physical activity and behaviour change modules built into the core basic training of health professionals.

— Clear messages about healthy eating and physical activity for all age groups.

3. Encouragement

Motivating and prompting people to make the necessary changes to their lifestyles here and now; and triggering action. Examples include:

— Active play for pre-school children.

— Sports and games in schools.

— Media campaigns (eg the Department of Health's "Five-a-Day" campaign to promote the consumption of fruit and vegetables; the Health Education Authority's "Active for Life" campaign to promote a more active everyday lifestyle)

— Trigger messages (eg low fat/sugar logos on packaged foods; low calorie options on menus; walk prompts on lifts and escalators).

— Healthy walks groups.

— Sports clubs.

— Fun-runs, aerobathons, and other mass activities.

— Life insurance health checks.

— Motivational counselling in primary care.

— Incentives/rewards for "active transport" (eg walking, cycling, etc) to school or work.

All three basic elements are essential and interdependent.



© Parliamentary copyright 2005	Prepared 2 June 2005