House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Memorandum by Which? (WP 27)

INTRODUCTION

1. Which?, formerly known as Consumers' Association, is an independent, research-based organisation that campaigns on behalf of all consumers. Funded through the sale of our range of magazines and other publications, we are the largest consumer organisation in Europe and have around 700,000 members.

2. Food and health issues have always been central to our work because they are central to consumers' lives. As you will be aware from previous evidence that we have submitted, much of our work has focused around tackling diet-related disease and obesity from a food perspective and so our evidence should be seen in this light. This is the area where we have most experience and have therefore largely focused our comments.

WHETHER THE PROPOSALS WILL ENABLE THE GOVERNMENT TO ACHIEVE ITS PUBLIC HEALTH GOALS

Overall approach

3. Which? strongly supports the approach that is set out in the Choosing Health White Paper[64] and the acknowledgement that the National Health Service (NHS) needs to improve health and prevent disease, not just treat those who are ill. It also recognises that if public health is to improve a multi-sector approach is demanded across central and local government, but also involving communities, industry, the media and other non-governmental organisations.

4. Central to the White Paper is recognition that government has a role in creating an environment that facilitates healthy choices and that there is a need to focus specifically on tackling inequalities in health. We believe that the right balance has been struck between individual responsibility, the role of government and the need for other relevant stakeholders and sectors to respond. The challenge is to create an environment in which healthy choices become the easy option, or as the White Paper describes it: "to empower people, support people when they want support and to foster environments in which healthy choices are easier."

5. With this in mind, we support the three broad principles that form the basis of the actions proposed: supporting informed choice, with a special responsibility for children who are too young to make informed choices themselves; personalisation of support to make healthy choices, with equal access to such services; and working in partnership to make health everyone's business. We also consider that the broad themes identified in the White Paper ie health in a consumer society, specific issues for children and young people, local community action, workplace health, health in the NHS and making health "a way of life" are the key areas to focus attention.

Ensuring effective delivery

6. We have, however, heard rhetoric about public health on many previous occasions—the challenge is to make the intentions set down in the White Paper real. While it does provide a firm basis for action, we are concerned about how it will succeed in motivating and co-ordinating the necessary actors across the board in order to sustain change and really make the sentiments set down in the White Paper happen. We are also concerned that there is too much reliance on voluntary co-operation by industry and are sceptical about the ability and willingness of some sectors to deliver the changes that are necessary. Much therefore will depend on the Delivery Plan and specific action plans on food and health and physical activity that are promised for early 2005.

7. The White Paper does set out some specific mechanisms for delivery including for example, the establishment of Local Area Agreements between government, councils and local partners on local delivery of national targets to reflect local priorities and which will initially be piloted in 21 areas from April 2005. Primary Care Trusts (PCTs) are also to be required to develop targets to meet the needs of people living in their area with local partners in order to meet national targets and priorities. It is also positive that health is to be included as a specific component of regulatory impact assessment— something that is long over-due and an essential step towards ensuring a consistent approach to public health across all government policies. The establishment of a specific target to halt the rise in obesity among children is also a useful way of monitoring progress. Given the importance of European Union (EU) action to help tackle many of the areas identified in the White Paper, we are pleased that the Government has also made "empowering people; reducing inequalities" a theme for the UK Presidency of the EU.

8. However, we believe that in addition there is a need for mechanisms to engage, co-ordinate and motivate the stakeholders across all sectors who are needed to deliver the aims set out in the White Paper. This needs to happen at national level as well as local level. Specifically, we believe that there needs to be a strategic body to over-see the delivery of the Food and Health Action Plan. As we proposed in our policy position paper "Health Warning to Government"[65] we consider that a Nutrition Council is necessary to take a strategic over-view, to co-ordinate, and to ensure that the main stakeholders make clear commitments and deliver on them. We acknowledge that the Health Committee also suggested that the Government should consider expanding the role of an existing body or bodies or creating a new Council of Nutrition and Physical Activity to improve co-ordination and inject independent thinking into strategy in its report on Obesity.

9. The Committee's report also recommended that a specific Cabinet public health committee be appointed, chaired by the Secretary of State for Health to ensure that the problem of obesity is recognised and tackled at the highest levels across government. While there is now a Ministerial Committee on Public Health (MISC 27) with a remit to "oversee the development and implementation of the Government's policies on public health and reduce inequalities", we are concerned that important agencies of government that have a key role in delivery, most notably the Food Standards Agency, are not represented on this Committee.[66] While this is clearly a Ministerial Committee, we note that the Chief Medical Officer is invited to attend.

10. It is essential that all parts of government—both central and local—also become fully engaged and accept their responsibilities as part of the delivery process and that an impetus for action is maintained across all sectors. The White Paper is ambitious and a great deal of commitment will be necessary, backed up by government incentives including regulation where appropriate, to achieve the culture change that is needed if we are to see an improvement in public health. These issues must be addressed within the Delivery Plan and specific Food and Health and Physical Activity Action Plans.

WHETHER THE PROPOSALS ARE APPROPRIATE, WILL BE EFFECTIVE AND WHETHER THEY REPRESENT VALUE FOR MONEY

Marketing health

11. The White Paper highlights the importance of marketing health, ie. promoting it on the principles that commercial markets use and therefore making it something that people aspire to, and the need for information to support healthy choices. We believe that these are important aspects, but are concerned that the proposals do not go far enough in some important areas.

12. We are pleased that the Department of Health (DH) intends to develop a strategy over-seen by an independent body that extends across all aspects of health and involves a broad range of different government departments and agencies, while also recognising the need for specific and targeted approaches. This needs to draw on the expertise of the marketing and advertising industries, while avoiding any potential conflict of interest, and use creative social marketing techniques. However, to be effective, such a strategy also needs to be closely linked to a broad range of government, community, industry and other stakeholder activities to ensure that consistent messages are promoted and that it is easy and practical for people to put them into effect.

13. As well as promoting positive health messages, it is therefore also important that misleading or potentially confusing messages which could undermine efforts to improve healthy choices are effectively tackled. This includes the way that messages are promoted through advertising and other marketing and promotional activities and information such as claims made on food labels. We welcome the sentiment set down in the White Paper that the Government now recognises that there is a strong case for action to restrict the advertising and promotion of foods high in fat, sugar and salt to children—and for this action to be comprehensive and taken in relation to all form of food advertising and promotion. Our research has shown that this is an issue of great concern to most parents and that they are supportive of greater restrictions. For example, a Which? survey in 2003 found that 70% of parents believe that there should be no advertising of junk foods during children's viewing times.[67] However, we are concerned that the White Paper is short on specifics about what the Government intends to do to address this—passing the issue back to Ofcom for further consultation.

14. While it is encouraging that the Government intends to work with industry, advertisers, consumer groups and other stakeholders to encourage new measures to strengthen existing voluntary codes in non-broadcast areas, we are concerned that this is too weak. The Government states that it will monitor the success of measures in relation to the balance of food and drink advertising and promotion to children by early 2007, but we would like to see firm action to tackle the problem sooner, based on the evidence that has been provided by the FSA commissioned Hastings review[68] and the research commissioned by Ofcom.[69] We would like to see an explicit commitment to tackle this area, including a commitment to restrict the advertising of such foods during children's viewing times. We would also like to see the Government pushing this message in Europe in the context of the review of the Television without Frontiers Directive.

Information to Support Healthy Choices

15. It is very encouraging that the Government has recognised the need for consumers to have simple information that they can trust. We particularly welcome the commitment to introduce a simple sign-posting or coding system for foods by 2006. This is something that we strongly supported in our written and oral evidence to the Health Committee's Obesity Inquiry and we were therefore pleased that this was included among its recommendations.

16. It is important that industry signs up to such a scheme and that we are not presented with a proliferation of simplified labelling schemes which only serve to create further consumer confusion. It is essential that the Government over-sees and drives this forward. It is disappointing that at the moment some parts of industry do not appear to support such an approach or accept that consumers favour a simple sign-post labelling scheme. Others are developing their own schemes which is encouraging—but unless these schemes are consistent, they will merely lead to more consumer confusion. We are therefore very supportive of the research work with consumers currently being undertaken by the Food Standards Agency to decide which is the most suitable labelling format. We are also pleased that the Government will be pushing for improvements to nutrition labelling as part of the UK Presidency of the EU.

17. It is also essential that the EU develops tighter controls over health and nutrition claims and fortified foods to protect consumers from being misled. Far too many products are misleadingly promoted as healthy, including some supermarket healthy eating range products, when they are still high in fat, sugar or salt, as we highlighted in our recent report "Healthy ranges—the slim truth?".[70] Which? briefings on the EU proposals for legislation in these areas are enclosed.[71]

18. In terms of consumer information, we also welcome the creation of Health Direct with the aim of achieving a joined up approach with existing services, as well as new funding to enable every Primary Care Trust (PCT) to run at least one Skilled for Health programme each year, by 2007, focusing first on the most deprived areas. We also support proposals for more tailored approaches to information and support for healthy choices, including for example children's health guides as part of the Child Health Promotion programme, but also proposals for NHS health trainers and personal health kits.

Industry Responsibility

19. As we have already emphasised, industry has a key role in tackling the barriers that make it difficult to make healthy choices. We therefore welcome the White Paper's acknowledgement of the important role that industry must play and of the public's expectation for industry to act in a socially responsible way. Four key areas are identified for the food industry, which we agree with: product development, labelling information, promotion and pricing and customer information and advice.

20. We agree that the food industry has a responsibility to increase the availability of healthy food and welcome the commitment to establish long-term and interim government targets for reductions in sugar and fat levels in different categories of foods, building on the work already under-way on salt, and to develop guidance on portion sizes. Research that we have carried out comparing the nutritional content of breakfast cereals[72] and of ready meals[73] has highlighted the huge variations in fat, sugar and salt levels depending upon which brand consumers choose and therefore the scope for making reductions. These two reports are enclosed.

21. While we hope that industry can respond constructively and act collectively to tackle the key issues, it is important that the Government carefully monitors progress and ensures that there is an adequate response. If industry does not respond, the Government must use regulation to drive responsible behaviour. As highlighted above, we remain concerned about the proposals regarding the important area of food marketing and promotion. We are sceptical of the industry's willingness to accept responsibility in this important area. Government action is therefore essential to ensure that failure to tackle any contradictory messages and promotions here, does not undermine the other commitments and proposals set down in the White Paper and the forthcoming Food and Health Action Plan.

Children and Young People

22. We welcome the acknowledgement that children need particular protection. We agree with the intention behind the Child Health Promotion programme to create a broad-based programme of support that will "address the wider determinants of health and reduce health inequalities". This needs to address the complex interactions that come into play. For example poor nutrition may affect mental health and in-turn mental health can lead to people adopting negative health behaviours such as smoking and alcohol abuse. A co-ordinated and multi-faceted approach is therefore essential in order to tackle the different elements and address the particular problems of different groups. It will be important that local services work in a joined-up way across health, social services and education—and at local and national levels. It is essential that support is provided, and provided appropriately, at all stages of a child's development.

23. We are, however, concerned that the proposals for schools are not ambitious enough. We do not think that it is sufficient to aim for half of all schools to be healthy schools by 2006, with the rest working towards healthy school status by 2009. We are concerned that this timetable is too long and would like to see proposals for all schools to become healthy schools as standard. We support the commitment to role out a "whole school approach to healthy eating and drinking". However, we would again like to see this as standard and see a greater emphasis on the teaching of food skills as part of the national curriculum.

24. We are, however, pleased that the Government has more specifically committed to improving nutrition in schools, including revising both primary and secondary school meal standards and extending these standards to cover food across the school day—including vending machines and tuck shops—and supporting school meal service provision. We also welcome a similar approach to catering in other institutions and public bodies, building on this work.

WHETHER THE NECESSARY PUBLIC HEALTH INFRASTRUCTURE AND MECHANISMS EXIST TO ENSURE THAT PROPOSALS WILL BE IMPLEMENTED AND GOALS ACHIEVED

25. We do not consider that the necessary infrastructure and mechanisms currently exist to deliver on the proposals set out in the White Paper. However, we do believe that the White Paper is a very useful starting point that now needs to be built upon through concrete steps including clear commitments at all levels and adequate resourcing.

26. Some of the measures that are set out in the White Paper will help to make delivery achievable. Primary Care Trusts (PCTs), for example, have a key role as a promoter and facilitator of good health in local areas, but must engage actively with the local community and community groups on the basis of an equal partnership. It is also important that local targets are focused on the issues that make sense and which are important to local communities, and that they focus on outcomes not just outputs or what is easily measured. Adequate resourcing by government for these initiatives will be crucial. It must be ensured that money given to PCTs for the purposes set out in the White Paper is actually spent on public health measures. It must also be ensured that PCTs have the capacity and the competence to take on this leading role.

27. The White Paper does, however, set out an ambitious vision that requires a new approach at both central and local government level as well as within the NHS. Some measures even require action at European level if they are to be put fully into effect. New challenges are also raised for communities, companies, consumer and public health organisations, the media and for individuals—actors at every level. We believe that we will only begin to see change, and change that can be sustained, if there truly is a multi-stakeholder and multi-sectoral approach to tackling public health. This requires a great deal of motivation, enthusiasm, specific commitments and perhaps most of all, effective and sustained leadership and co-ordination from central government.

CONCLUSION

28. We consider that the approach set out in the White Paper is the right one, but we have concerns about how the proposals will be delivered in practice. We therefore look forward to seeing how these issues will be tackled within the Delivery Plan and the specific Food and Health and Physical Activity Action Plans which must be a priority. As we have already highlighted we believe that there is a need for strategic, cross-sectoral and cross-governmental structures to be put in place if the aims of the White Paper are to be achieved and the momentum and enthusiasm that is needed to deliver better public health is to be sustained in the longer-term.

January 2005