Examination of Witnesses (Questions 80-99)
23 FEBRUARY 2005
RT HON
JOHN REID,
MP, MISS MELANIE
JOHNSON, MP AND
DR FIONA
ADSHEAD
Q80 John Austin: Why 2010? 2010 seems
a long way off.
Miss Johnson: That is all by 2010.
I have many schools in my constituencies that already have them.
I am sure other Members likewise have a lot of schools that already
have them. The question is just making the progress through to
the end of that. There are issues for some schools in the routes
that children would have to walk and getting volunteers and getting
things set up. It is not all straightforward in all environments.
But just to go back to the earlier point about air quality, and
so forth, and hazards on the road, all of these things contribute
much more to things like accident reduction ultimately and a healthier
environment as well as people themselves being healthier, and
in a lot of cases it will encourage more adults to walk. In one
of the examples I saw in the country where they had encouraged
children to walk to school they had done it by clearing drug needles
out of an area, making the path much better, a direct path and
having some adults along it, which other than helping young children
going to school to walk in that environment was creating a much
better environment in that community. Going back to the point
the Secretary of State was making earlier about the involvement
of the local authorities, we do think that it is absolutely crucial
to the delivery of the White Paper and I think throughout much
of this you have not perhaps been questioning as much as anything
that we need to get it delivered.
Q81 Chairman: That is the next session!
Miss Johnson: But let me tell
you, Chairman, we are very fixated on the fact that we have to
get this delivered because we do not want it to be just another
White Paper on public health. We want things to happen and it
is the partnerships, for example, with the local authority on
things like walking and cycling which are going to be absolutely
crucial to making that particular strand and a number of others
happen on the ground. It is not only the health service and it
is not only public health.
Q82 John Austin: I welcome the development
of safer cycling routes to school and the links with the cycling
network, and it is specifically mentioned in the White Paper.
The amount of money put forward by the Department for Transport,
however, was a one-off and it is not a rolling programme, so I
wonder if the Department of Health might have some influence with
the Department for Transport to ensure that it is a rolling programme
of the expansion of links to the national cycle routes?
Miss Johnson: We are obviously
working closely with them. One of the other things is on cycling
proficiency, where we are determined to get cycling proficiency
training in again. Many of us learned to ride a bicycle and then
were given proficiency training as young people. That has tended
to go out of circulation. We want that to be available to young
people across the board again and we are looking at ways to make
that happen and working closely with the Department for Transport
on things like that.
Dr Reid: Just one comment from
Fiona.
Dr Adshead: I think in terms of
encouraging PCTs to engage in active travel, we are working with
and have funded Sustrans to work with the NHS to develop green
travel plans so that we hope that that will promote the kind of
action that you were suggesting.
Q83 John Austin: I know that targets
are touchy issues, but I note that the Department for Transport
has abandoned its targets for increasing cycling levels. Perhaps
that is something you might enter into some discussion with them
on?
Dr Reid: Yes. I think I may have
introduced that target as Minister for Transport! I am deeply
offended if that is the case. I am moving so fast, you know, there
is every chance I could end up there again! Thank you for letting
me know.
Q84 John Austin: Can I take you to safer
areas and come back to the promotion of sport and physical activity.
I think we all acknowledge that there has been an unprecedented
investment in sport in schools in recent years, but the target
which is talked about in the White Paper is the two hours per
week of physical education or sport. Are you satisfied that that
is within the curriculum time? Are you satisfied that that is
enough, and is that going to be real physical activity rather
than talk about physical education?
Miss Johnson: All the evidence,
interestingly, is that aside from English, maths and science the
next biggest chunk of the curriculum given over to any subject
is to PE, which is good. You are right, obviously we do have the
two hour target. We also have, as the Prime Minister unveiled,
half a billion pound boost for PE and sport in schools in December
of last year. He announced at the same time that we would have
even beyond that four hours of high-quality PE and school sport
each week by the end of the decade as a target. Now, some of that
is within the curriculum time of schools, within the taught time,
but some of it is obviously outside of those. It is by extending
school, it is by doing things at weekends and at other times,
but that would provide an even wider number of hours with very
active children. I also say, as for adults what we need to do
is to increase the way in which exercise is embedded naturally
into children's lives, as it should be for adults. So more walking,
more cycling of an every day kind as well, more of a general physical
activity around. I am worried about the Chairman's retirement
on to his sofa in front of his television and I think his pedometer
will serve him well in the future, because I think that what we
do not want to do is to have people generally with sedentary lifestyles,
and that includes young people. So I think that whilst sport is
enormously important and we are putting huge investment in it,
we are not saying all our eggs are in that single basket either.
Dr Reid: Very briefly, I managed
to discuss a number of things, including nutrition in schools,
with the new Secretary of State for Education. I have not discussed
this, but I know from the general discussions about her philosophy
of education and her own background and commitment, which to some
extent I think was displayed today when she talked about the basics,
that she does believe in an ethos of the whole person and I would
not be at all surprised if sport and physical activity was a very
important part of her view of a healthy developing young child
along with English, maths and the other things she was speaking
about today.
Q85 John Austin: Perhaps you might also
talk to her about how schools might develop more out of hours
school sport as well and how those facilities might be developed?
Miss Johnson: The extended school,
obviously, and the children centres as well offer opportunities
for extending the range of what is being done both within school
and outside of school.
Q86 John Austin: The other issue which
has arisen is that surprisingly, I think, it came to us that there
is a lack of physical activity often with pre-school children.
I wonder what the Department is doing to encourage more physical
activity for pre-school children?
Miss Johnson: The Sure Start schemes
obviously look particularly at all aspects of young children's
health, particularly families who are involved with Sure Start,
which we have got very extensive Sure Starts and the children
centres will be taking quite a lot of that in, as it were, and
developing it. I saw myself in Devon just a few weeks ago at a
healthy living centre young children coming in for help with physical
skills who needed more physical skill development and were coming
in for a structured programme with parents or helpers to help
them develop the skills at a very young age, tots two, three years
old, who need additional help. So there is a range of programmes
for those with particular needs through to those who just have
a more general but important need. I agree with you. I think it
is very important that they start young, but all the evidence
also is that we need to get it right right across the primary
schools because if by the time they go to secondary schools they
do not have the skills to participate in sport and a general physical
fitness then very rapidly they drop out or cease to be really
engaged in the things which are going to give them long-term well-being.
Dr Reid: We have been working
on a physical activity plan, which is due out next month, and
the importance of play in that healthy development. You may be
interested to know, I do not think the Minister mentioned, just
briefly, there is a lot of money being spent on this including
the Lottery money. I think the Government is investing something
like £1.5 billion in sport and PE over the 2003 to 2008 period.
Sport England last week announced, I am told here, £350 million
funding for sport.
Q87 Chairman: Good. I know that one or
two of my colleagues want to come in on this issue before we go
on to delivery, which Richard will lead on in a moment, but when
we did the obesity inquiry some of us spent some time at Bradford
Bowls Rugby League Club looking at what they were doing on health
issues with local schools and we were very impressed by the connection
between professional sport and health education. I am conscious
of some frustration among a range of sports. I think there is
a huge willingness to get involved in the health agenda but a
feeling that in a way they cannot seem to get access to where
they can work with PCTs or the Department. One example that I
would certainly ask you to look at is where I attended a meeting
in the House of Commons a couple of weeks ago, a unique meeting
which drew together both codes of rugby, which have not had the
greatest relationship for 105 years, but working together on a
proposal for what is called a 30 minute squad where they have
got a series of professional players willing to go into schools
as role models and work with youngsters, but they are finding
difficulty in establishing a way into the system to do that. I
know that they have talked to somebody who has been very helpful
in the Department, but I think the sort of way in will be at PCT
level. But it is very difficult for them to know how to do that
without the blessing of the Departments at a national level. I
do not think it is just the two codes of rugby, I think it is
other sports as well that have a lot to offer and genuinely there
is a willingness to move it forward.
Dr Reid: We are completely at
one on this, Chairman. Right from the beginning of the consultation
and my beginning as Secretary of State for Health I believed that
on this issue we needed to think out of the box because I used
to say that people from the area I come from, and certainly yours,
are not deeply impressed by people called Sir Nigel Crisp or Sir
Liam Donaldson, Chief Medical Officer, telling them how to live
their lives, or me, some Cabinet Minister telling them how to
live their lives. However, if the local football manager or the
local rugby club decides that they are going to get involved in
something at a school level upwards, the rugby club and the football
manager, and so on, will have a far greater effect. So we have
been trying to do this and you are right, there is a problem here
because if you are decentralising power to the locality how do
we steer this from the centre by engaging with people like rugby
clubs, and so on. Fiona has been working with this. We are working
closely with the Department for Culture, Media and Sport, Sport
England and the professional bodies such as the football clubs,
the Football Association, the Premier League and also Premiership
Rugby on this. But I think what we have got to try and do from
the centre is two things. One is to make the information available
to the primary care trust and encourage them to do so. So you
make the information available. We are now doing that, are we
not?
Dr Adshead: Yes.
Dr Reid: We are saying to them
at the primary care level, "Get in touch with your local
rugby club, football club, and so on, and identifying the contacts
and all the rest of it," but the second is in order to encourage
them rather than just informing them to do that we are now holding
a series of regional seminars for PCTs and sports clubs. So that
is trying to combine our role at the centre with devolved decision-making.
It will still ultimately be up to the primary care trust. Your
view, and presumably that of your Committee which you have just
expressed, is entirely in accord with us. I cannot say how supportive
we are of what you are saying. It is not being delivered on the
ground yet and we want it to be, and we want to cut through the
bureaucratic fog which sometimes prevents this from happening.
Chairman: That is helpful.
Q88 Mr Jones: Secretary of State, on
Monday I was with two of my constituents and their family, Mr
and Mrs Underwood, outside a swimming pool with their two eighteen-month-old
twins and their three-year-old and we were prevented from going
into the swimming pool. There will be another four years before
the two parents are able to take the three children into the swimming
pool and there will be another six years before any one parent
could take the three children into the swimming pool. Could you
ask the Secretary of State for Education, who I am sure is well
aware of the problems of having young children, that this is an
absolute madness and to somehow allow local authorities to act
responsibly rather than just be defensive and ensure that there
is no chance in a million they can ever get sued but on the other
hand no young children will ever learn to swim?
Dr Reid: I will both raise this
with the Secretary of State for Education, who as you say at this
rate it may be several decades before she can take all her children
to the swimming pool, and with the Department for Culture, Media
and Sport because I think they have the responsibility for that
coverage. I am afraid I only have read about this, I do not know
it in detail, but I accept the description you give of the problems
that will be faced and I will certainly raise it with both of
them.
Q89 Mr Amess: Before we get on to the
final section of delivery, which I have certainly got a few points
I wish to raise on, I want to ask two or three questions about
mental health. I would like to know why is the nation's mental
health given such a low priority in this White Paper? I think
we turn to page one hundred and thirty-one before it is mentioned,
section 37, where we are told: "Transforming the NHS from
a sickness to a health service is not just a matter of promoting
physical health. Understanding how everyone in the NHS can promote
mental wellbeing is equally important—and is as much of
a cultural shift." This should have been said at the start
of this White Paper, not left to page one hundred and thirty-one.
Dr Reid: The reason is precisely
because we thought it was as important as you are making it out
to be that we decided not to incorporate all of it inside the
White Paper but to have a section in the White Paper which referred
to it and simultaneously to develop and publish, which we have
now done, in the immediate aftermath of the White Paper a full
national service framework on mental health, which is the first
time that has ever been done. So I am the first to accept, Mr
Amess, that mental health has been up until very recently the
Cinderella in terms of health, but I assure you that the reason
why there was, if you like, a summation towards the end of the
White Paper was because it was about the only subject in the White
Paper where we were doing a separate, more detailed and more directive
section of the national service framework outside of the White
Paper so that there is a cross-reference.
Q90 Mr Amess: Two questions following
from that. I think at the start of the afternoon we talked about
health trainers. What skills will these health trainers have in
dealing with people who have mental health problems, or are they
going to be left out of this equation?
Dr Adshead: The principle of health
trainers is that they will be trained in health psychology techniques.
So they will really understand what makes people tick and they
will really understand their motivation. One of the points we
make in the White Paper, and maybe we could have been more explicit,
is that in order to make any healthy choice you need to have a
certain level of confidence and a certain level of emotional wellbeing.
So understanding people's motivation and building that kind of
confidence will be key to the role of health trainers, and we
do have a number of commitments in the White Paper around emotional
wellbeing linked to Sure Start, the importance of it in healthy
schools programme, very much building that kind of confidence
and life skills as children grow up. So it is core to the White
Paper but I think you are right, we might have done more to bring
that out and make it more explicit.
Dr Reid: It is one of the six
key priority areas.
Miss Johnson: You and the Committee
have been talking for some time about aspects of mental wellbeing
in terms of thinking about what enables people to change their
lifestyles just like the issues about people's ability, if they
are in poor circumstances, to look after and change their own
health. A lot of that is about their mental wellbeing, and interestingly
on your earlier point about the sports clubs, when I saw what
Middlesbrough, for example, as one of the premier clubs who are
doing things of the sort that you are talking about now are doing,
one of the things they are doing is building self-esteem and self-confidence
in the work that they are doing with both young men and young
women from their own community in doing the sorts of programmes
that they are doing which looks like physical activity but is
much more subtle beneath that, and I think the connections are
very important and you are quite right to emphasise them.
Q91 Mr Amess: I am really pleased to
hear this anyway. That is good.
Miss Johnson: We accept entirely
that those connections have got to be made and built.
Q92 Mr Amess: Okay. Excellent. The final
point I wanted to ask is what measures will be used to assess
improved mental health within the 88 Primary Care Trusts which
have been chosen to be the first to get funding? Have you got
any information you could give the Committee about that?
Dr Reid: The spearhead. Do you
mean in advance or in addition to—
Q93 Mr Amess: What measures will be used
to show the improvement?
Miss Johnson: First of all, all
the PCTs including those who are covered in the spearhead, the
eighty-eight in the spearhead group, will have to produce local
delivery plans. There are some core areas where they have to produce
what their plan is to contribute to things like, for example,
reducing child obesity and various other strands like smoking,
including pregnancy. Then they can add other areas on to that.
We will be checking their delivery against those plans. The Strategic
Health Authorities will be doing that on our behalf. They will
be supporting and monitoring that delivery. One of the things
we will be doing is that and at regional level we will be producing
six monthly reports on progress, which is the aim, as well. So
there will be a whole variety of measurements going on and checking
that we are making progress on things across the board, and that
will cover this area as well as many others.
Mr Amess: Okay. We are on to delivery
then inadvertently.
Chairman: I am conscious that we have
kept you two and a half hours. We hope to conclude fairly soon,
but before we do perhaps some shortish questions on delivery,
Richard.
Q94 Dr Taylor: Delivery. I am sure we
are all very encouraged to hear that you are determined to see
the White Paper delivered. One thing which slightly bothers us
is, I think you are going to give six month progress reports on
the implementation but we are very worried about whether you are
going to have the up to date information to do that because if
we look at the information you have got about smoking levels these
are about two years old. How are you going to be sure you have
go the up to date information to be able to tell us that you really
are achieving?
Dr Reid: First of all, in terms
of monitoring delivery we will have local targets, as I think
Melanie has just said, in a whole series of areas, one of which
is smoking. So at the locality they will be monitoring these and
we will have to monitor them to see that they are delivering them.
In addition to the local targets, which are core targets incidentally,
there will be some others because the PCTs can choose them and
the performance levels within these targets (particularly the
core ones) will have to be agreed between us and we are in the
process of discussing these things now. So there will be a system
whereby there is an allocated target on that and where it will
be monitored. In the spearhead PCTs, which is the area Mr Amess
was asking about, the Strategic Health Authorities there will
ensure that they are making faster progress than the average primary
care trust in these areas because they are getting more money
by and large and they are getting money earlier by and large because
they have got greater problems. So there will be a degree of monitoring
which is not there. I think this has already proved effective
in some areas and the one example I would give, and it is what
I said at the beginning, I do not agree with everything that Derek
Wanless has said any more than he agrees with everything I have
done, but if you look at the smoking cessation services we have
something like now eight hundred thousand four week quitters through
the NHS stop smoking services target and that has worked to motivate
the NHS to deliver. They have seen that they can work this, and
they have seen it can work because we were prompted to start looking
at the figures because people like Derek Wanless were saying,
"You don't have the evidence for this. This is an expenditure
and I don't want to waste any money." So we started to look
at it and you will see there are eight hundred thousand. So I
can tell you that some three hundred and thirteen thousand people
since April 2003, which is just before I came in because I wanted
to know how many people stopped through smoking cessation services
roughly since I came in and from the financial year starting in
2003 three hundred and thirteen thousand people have quit smoking
with the smoking cessation services. So we are now, Dr Taylor,
beginning to monitor it so that we can be reasonably sure that
in most of the areas we will have a pretty good guide as to whether
we are delivering or not.
Q95 Dr Taylor: When you have made the
plans for monitoring would we be able to know the details of the
sorts of things you are going to monitor so that we know how to
follow?
Dr Reid: Yes. I do not see any
problem with that at all. There are four main areas. We have got
improvement in the health of the population as a whole. So let
us agree how we are going to measure that. Now, we have got a
problem there with the Office of National Statistics because—
Q96 Chairman: Do not get him going on
that one, please!
Dr Reid: Right, but at least we
can work on a rough assumption that if you die we have not succeeded
and that if you live there is a quality element here that ought
to be taken into account. So you have got the health outcomes
of the nation as a whole, who is smoking, who is not smoking,
and so on. Then you get improvements in the level of quality of
service delivery. That is data submitted by the Strategic Health
Authorities, and so on, for instance, to measure the forty hour
waiting time target for sexual health access. Then you have got
the reports on the delivery of publicised project milestones and
trajectory, in other words the ones where we say, "Here are
the milestones we want to hit." Then you have got inspections
carried out by the Healthcare Commission that we have established
and others. So there are at least four major ways of measuring
and we intend to do this through six monthly reports and we are
more than happy, given the partnership we have had with the Select
Committee in fashioning this, to share with you our information
as we go on.
Dr Adshead: Our technical guidance
note that goes out as part of our primary care trust details the
specific monitoring lines they will be asked to look at, for example
measuring body mass index in the adult population, and this week,
on Monday, we supplied them with the planning tool-kit which gives
them a bit more advice and a bit more support on how they might
go about doing that and what is best practice, what we are calling
the sort of "big wins" would be to ensure local delivery.
Q97 Dr Taylor: Did you say that has gone
out?
Dr Adshead: The technical note
went out in the autumn, around November, but the tool-kit, which
gives the more detailed information, went out this Monday.
Q98 Dr Taylor: Are they being instructed
to weigh and measure children at school?
Dr Adshead: We are working with
the Department for Education and Skills on that.
Dr Reid: We are having a discussion
with the Department for Education about that matter.
Miss Johnson: Implementing it.
Q99 Chairman: Can you be a bit more specific
about the issues around that because it was something that I think
we were surprised about?
Dr Reid: About skills? Yes. The
one thing that Charles Clarke and I agreed on was that we needed
to put health more at the centre of what is happening in skills.
That had a number of dimensions. One was to make sure, just in
the same way that I believe better off people could get access
to advice and personal trainers then we should give something
of that nature to people who were not so well off because we assumed
it was a good thing. So we believe that if in schools where people
pay for their kids to go to the central role is played by the
school nurse, there should be at least one school nurse for every
cluster of schools. That was the next thing. Then there was nutrition
at school, which we are dealing with as well. The other thing,
which was slightly more problematic, was to decide what we could
agree on in the monitoring of the development physically of a
child at school. I think it is fair to say there are different
views on how you should do this. My old-fashioned instinctive
way of doing it was to say you measure people, their height and
their weight and look at their arms, and so on, every so often,
but people who are much better educated than myself in medical
techniques told me that this was an unproductive use. I am not
looking at Fiona because she was the one who told me, but others
who have said that this was not the most productive way to do
things. So we came to a sort of compromise at this stage and we
are continuing the discussion. Would you like to just tell us
about it, because I think the Committee would be interested.
Dr Adshead: We do have national
monitoring information, as you are probably aware, through the
health survey for England so we know the proportion of children
who are, for example, overweight. We have information on average
weights for children at different ages. We are in active discussions
with the Department for Education and Skills. There may well be
a mechanism for school nurses to measure obesity One of the things
we need to make sure, though, is that when we are measuring school
children we need to do that sensitively so that we do not stigmatise
them, we do not make them feel miserable because somebody has
told them that they are overweight. So we are taking it very seriously
because we absolutely do need to know the extent of the problem,
but we are trying to do this in the best way, putting children's
best efforts at the heart of how we are approaching this.
Dr Reid: So what looked to me
like the simple solution, you see—and this is where Mr Amess's
point comes in—is not always the simple solution because
you have to see the whole child and the psychological effects,
and so on, of it. So we are continuing discussions about how we
might do that.
| 
