Joining Forces to Tackle Obesity, 21-22 January 2002
Transcript : Introduction and Context
Introduction
James Robertson, Director of Health Value for Money Studies at
the National Audit Office
Sir John Bourn, Comptroller and Auditor General, National Audit
Office
The Context
Yvette Cooper MP, Parliamentary Under-secretary of Sate for
Public Health
JAMES ROBERTSON: Good morning. I am very
pleased to be able to welcome you here for this the National Audit
Office conference on obesity, for the next two days. My name is
James Robertson, I am the Director of Health Value for Money
Studies at the National Audit Office, and I am just going to run
through a few brief housekeeping details. Beginning with the fire
precautions. The details are in your delegates’ pack. There is no
test fire alarm today, and if you hear a continuous siren, then we
need to evacuate immediately.
Refreshments are served, you have probably discovered, upstairs
in the King’s Suite, one floor up, and may I finally ask you to
silence or turn off your mobile phones please?
I’d like to begin the business of the conference by inviting our
Chairman for this morning, the Comptroller and Auditor General Sir
John Bourn to address you. Sir John.
SIR JOHN BOURN: Ladies and gentlemen, it’s a
great pleasure for the National Audit Office to welcome you to this
conference. It’s also a particular pleasure for this first session
for me to welcome Edward Leigh, who is the Chairman of the
Committee of Public Accounts of the House of Commons, and Yvette
Cooper, who is the Minister for Public Health, who will be joining
us shortly.
You may in fact be surprised to be attending a conference on a
subject like obesity, organised by the National Audit Office. Some
of you may think that we’re the men and women of the shadows, bent
over the ledgers, our lives confined to some kind of Dickensian
counting house. Well, yes, we are concerned with the accounts of
British government. We are the auditors of some 550 accounts and
some £600 billion a year. But we’re not only concerned with the
money in the technical sense of accountancy, we’re also concerned
under the National Audit Act with the economy, efficiency and
effectiveness of government programmes. It’s not for us to question
the policies of the government, but to examine their outputs and
outcomes. In short, to look for the conditions of success and to
report to parliament by convention to the Committee of Public
Accounts, whose Chairman is here and will be talking to you this
morning, and the Committee of Public Accounts makes their
recommendations to the government. So where’s the procedure? Why
have a conference as well? It would seem to us that if behaviour is
to change, if ideas are to be exchanged, it’s not enough for the
National Audit Office to produce a report. It is valuable and
helpful to promote dialogue, debate and discussion, and so that is
why we arranged today’s event and why we are very pleased indeed to
welcome you.
If you look then, at the subject, it is a strategic objective of
the Department of Health to reduce avoidable illness, disease and
injury within the population. So that’s the policy, that’s the
objective. That’s what we take as read, and within that there’s a
national priority to reduce coronary heart disease and cancer, and
progress here very much depends upon reducing rates of obesity, and
the worrying fact is the rates of obesity have trebled in the last
20 years. I know you can argue about how to define obesity, but by
the definitions of the medical profession, one in five people in
this country are obese and the health consequences of obesity are
significant. You see them on the slide here, the number of days
lost through sickness. The number of deaths and the shortening of
life and everything that means for families, for failures of
fulfilment through early death, and as well as health consequences
there are the financial consequences. It’s not our exclusive
concern, but matters which we are very naturally concerned to note.
And we have some outline figures on this third slide.
To make progress of course, does depend upon a
cross-governmental approach. It requires the focus of activities
from a range of government departments and organisations. Those of
you who may have had the chance to look at our report on obesity
and certainly during this conference, it is important to recognise
that for progress to be made, it requires a concerted effort from
the Department of Culture Media and Sport, and the contribution of
physical activity. For the Department of Transport, local
government of the regions, for the provision of facilities which
enable those activities to take place. For the Department for
Educational Science, for taking account in the teaching of children
of health and lifestyle matters. In the Food Standards Agency, for
everything that their responsibilities cover and of course, for the
Department of Health. So, with so many aspects of public
administration today, progress depends on co-operation, on working
together, on understanding a common objective and making progress
towards that.
So, I am delighted as I say, to welcome you all to the
conference today, and I’d like for our first substantive speaker,
to introduce Yvette Cooper who is the Minister for Public Health.
We’re delighted, Minister that you could be with us, and we’re very
pleased and are looking forward to what you have to tell us. Thank
you very much.
YVETTE COOPER: Thank you very much. It’s a
great pleasure to be here today and see so many people here at this
conference on what is such an important health issue. I would like
to pay tribute first, to the work done by the National Audit
Office, and by the Public Accounts Committee on obesity. The work
that they’ve done to highlight the health problems that it poses
and to raise the issue very much on the agenda, not simply on the
public health agenda but I think across the board. We very much
welcome the report. It will help to shape future action. We will be
responding to the report formally in due course, and I wanted to
really take the opportunity today to set out, I think, some of the
areas where we have made progress so far, but where we clearly need
to build for the future and the areas that we will of course need
to review in the light of the report that has come out both from
the National Audit Office and the findings of the Public Accounts
Committee as well.
You will of course be aware of the stark facts. In England a
staggering four million women and three million men are now
suffering from obesity, and in the last 20 years, these figures
represent a three-fold increase in the prevalence of obesity. We
know that this is not just an English problem, it’s not just a UK
problem. It is an international problem. It’s a phenomenon observed
in many countries across the world, and interestingly, it is a
phenomenon that no country has yet come up with a perfect solution.
The NAO report I think, makes extremely clear the damaging impact
that obesity has on the health of our nation, both the impact on
the individual in terms of the impact on health and life
expectancy, but also the huge financial cost to the NHS and for the
community as a whole. In 1998, 9,000 deaths related to obesity
occurred before the state of retirement age. That’s 9,000 lives cut
short in their prime. The public health agenda that was set out to
saving lives white paper and through the NHS plan is very much
focused on tackling the big killers, and by 2010 we aim to reduce
the death rates from coronary heart disease and stroke by at least
two fifths in people under 75, and the death rates from cancer by
at least a fifth in people under 75, and these are the chief
clinical priorities for the government. But because obesity is so
strongly associated with cancer, heart disease and diabetes as
well, tackling obesity is vital is we’re to achieve those targets
and to reduce the burden of ill health and to save those lives from
cancer and heart disease and tackle diabetes too.
In women for example, researchers have found that obesity is the
third most powerful predictor of cardiovascular disease after age
and blood pressure, in part because of the strong associations with
high blood pressure and cholesterol. And diabetes is three times
more common among people who gained 10 kilograms of weight, and 75%
of people with Type Two diabetes are overweight. Furthermore the US
data indicates that 10% of all cancers among non-smokers are caused
by overweight or obesity.
I don’t know if you will be aware, we have produced a series of
national service frameworks that provide a plan for the prevention
and treatment of disease. These provide a means of driving up
quality across the NHS, defining service models, setting national
standards, not just on treatment but on prevention too. And
prevention is at the heart of those. Particularly I want to
highlight the national service framework on coronary heart disease,
and also the new national service framework standards for diabetes
that were published just before Christmas. Chief of those NSF’s are
development of local strategies on prevention and management in
primary care, but also across the community, and that means primary
prevention across the community but it also means secondary
prevention for those with cardiovascular disease, for those with
diabetes as well. And I want to say a little bit more in a moment
about the implementation of those national service frameworks and
the challenges that we face.
The Public Accounts Committee’s report, which I know that Edward
Leigh will be talking a little bit further about in a moment, have
made I think, a series of very important recommendations on how we
can step up actions to prevent and manage obesity, including issues
about cross-government working. Since the publication of the NAO
report and the Public Accounts Committee’s hearings and the result
of the report, we have already developed many of those partnerships
and announced further funding for a host of initiatives that are
likely to make progress in this area. But clearly we need to review
this in the light of the report, and I think the critical issues
that we need to bear in mind are firstly, what’s the evidence base
and what works to tackle the problem and to make a real difference?
But secondly, the importance of getting local ownership and local
implementation of the kind of action that will make a
difference.
We know that one of the areas we need to concentrate is around
childhood. Obesity is an important issue in childhood as it is in
adulthood, and the recent study, a systematic review funded by the
Department of Health concluded that children are considerably at
increased risk of obesity in adulthood if they are overweight in
childhood and/or their parents are suffering from overweight or
obesity, and results from our own National Diet and Nutrition
survey in the year 2000 indicates that about 10% of six year olds
could be classified as suffering from obesity, and four out of ten
boys and six out of ten girls are getting less than an hour a day
of physical activity.
The Atchison Report that was published a few years ago looking
at causes of health inequalities noted clearly that improvement in
the nutrition of schoolchildren should result in decreased levels
of obesity and in healthier patterns of eating in adult life as
well, and that this in turn could have an impact on the risk of
chronic diseases in adult life but also in the health inequalities
that can result.
Already we have action to improve children’s health underway.
For example, the National School Fruit scheme, under which infant
school children are entitled to a free piece of fruit every day. It
is the most ambitious programme to improve child nutrition since
the introduction of free school milk in 1946. It currently provides
free fruit to 80,000 children in 27 areas, and we’ve had a great
response to the scheme. It’s been extremely popular. Even more
popular than predicted among teachers, parents and among children
themselves, and there have been some quite startling anecdotes from
staff in some areas, because we started with some of the lowest
income areas in introducing the scheme. For example, teachers
saying that there were children who said they had never eaten a
banana before, or children who said they didn’t know what a pear
was until the fruit scheme was introduced.
Since the Public Accounts Committee proceedings, we announced
that £42 million of the New Opportunities fund money will be
available to extend the scheme over the next two years. So from the
summer term, all the schools that are in the West Midlands region
will be included, and thereafter further regions will come on board
as well. And in support of that, we have other programmes in
schools, such as the National Healthy Schools programme and the
Food in Schools programme to improve education and information for
children around food nutrition. On the activity side, in January of
last year the Prime Minister announced that all children will be
entitled to a minimum two hours a week of high quality physical
active education, and school sport will be beyond the school
curriculum and at the moment the DFES, the Department for
Educational Skills with partners, including the Department of
Health and including the Department of Culture Media and Sport are
working to develop a framework to deliver on this commitment. But
of course, the prevention and management of obesity is important in
adulthood and not just in childhood as well. The NHS plan makes a
commitment to local activity in this area, and we know that in some
areas there is a substantial amount of action going on. However, we
know too that there is room for improvement and there is often --
while some areas may be making huge progress, others are not.
That’s why we felt it was important to have the Health
Development Agency review. Not simply what is taking place at the
moment, but also crucially what actually works and what is making
the biggest difference in that area, in the context of the National
Service Framework for Coronary Heart Disease, and the review has
found that programmes in each area are at very varied levels of
development.
The response of the NHS shifting the balance of power to local
areas, particularly to primary care trusts, provide us I think with
an important opportunity to take this work further. Because primary
care trusts, through their health improvement role, to their closer
links to the local community and through of course the strong role
for primary care within them, will be absolutely key to delivering
local action on obesity. There’s provision for the Health
Environment Agency to provide further support for those primary
care trusts so that evidence on what works, on what makes a
difference, and I think we will also have, quite importantly, an
increase in the local public health workforce with public health
directors on every primary care trust, able to tey and implement
this work at the local level. The key is that we not simply use the
evidence base that we have at the moment in providing guidance to
primary care trusts, but that we review and continually improve
that evidence base as well as this action takes place.
Another important development has been the publication of
guidance last year by the National Institute of Clinical Excellence
on the use of the anti-obesity drugs, and prescription of these
drugs is recommended in combination with support and counselling on
diet and physical activity, and by having that guidance it means we
should expect more equal access to these drugs in the future in
every area. We’re also funding a number of research projects on
obesity prevention and management through the Department of Health
Nutrition Research Initiative, including for example, a randomised
controlled trial in four parts of the country on the impact of
providing brief advice and support on diet and physical activity to
obese patients during routine visits to the primary care
nurses.
But of course there is cross-departmental work and
cross-governmental work that is important here as well. We have to
recognise that people make their own choices about how they live
their lives, and it is not the government’s role to lecture people
on how to live their lives. But what we do need to recognise is
that the choices people make are often strongly influenced by their
circumstances, and very often the choice of a healthy life is not a
real one to many people. For example, some communities do not have
easy access to affordable fruit and vegetables. They do not have
pleasant open spaces, footpaths, cycle ways or affordable
facilities for sport and exercise, and this is where I think is the
most important cross cutting work can make a difference. Already
the government’s work on the "Five a Day" programme is aiming to
increase access to fruit and vegetables in low income areas, and
early results from the evaluation of the "Five a Day" community
projects that have taken place suggests that those on lowest income
and those who were eating least fruit and vegetables before the
projects began have increased consumption and that it has had an
impact in those areas. But it is important to remember that in many
of these areas we have quite a long way to go, and one community
worker who was interviewed as part of the evaluation said that for
her community, increasing intake to five a week might
actually be a big improvement.
Since the Public Accounts Committee hearing, the New
Opportunities Fund funding has provided an additional £10 million
to increase those "Five a Day" community projects across the
country. We also have the National Quality Assurance framework
published for exercise referral schemes in primary care, setting
quality standards for primary care for GP’s who want to be able to
refer patients to physical activity and not simply to drugs as
well, and this is about creating links obviously between the NHS
and leisure services. We have the investment going into providing
sports and exercise facilities as well, particularly into low
income communities, and work with other departments. For example,
last Thursday, Sally Keeble the Transport Minister and I, launched
the "Walk to Workout" initiative to increase access to walking and
cycling to work, which can have of course both health and
environmental benefits.
But the opportunities for this in terms of where we go for the
future are quite considerable at the moment. We have, for the first
time ever, a cross cutting review involving departments right
across the government to feed into the spending review decisions.
In other words, decisions about the priorities the government’s
funding over the next three to four years, and for the first time
ever, one of those cross cutting reviews is focused around health
inequalities. It includes work between the Department of Health and
the Department for Educational Skills on how you promote health in
schools, it includes work with DTMS on how we can promote physical
activity and increase access to physical activity and leisure
across the country, and it includes links with transport as well.
Into this, I think we need to feed the results of the NAO survey
and the results and the recommendations of the Public Accounts
Committee on action on obesity as well. It is an area where I think
a lot more can be done, but it is also an area where we have to be
quite humble I think, about what it is that will make a difference
and what it is that works in this area, because in the end, that is
the more important thing.
I hope that the conference today will be able to draw some
lessons, and be able to feed into that process as well involving
discussions about all the different aspects of prevention and
management of obesity. It is something that is very important to us
as part of those key clinical priorities, particularly on heart
disease, particularly on cancer and of course, in narrowing health
inequalities as well. There is a lot of good work underway at the
moment, there is a lot of potential here, but indeed there is also,
given the scale of the problem, a long way to go.
I will be very interested to see the results of your day and
your couple of days’ deliberations on this issue, and I wish you
well in the work that you do these two days, and I hope that you
will help contribute towards our process of discussing what next we
need to do to make a real difference in the prevention of
management in obesity, because in the end, ultimately this is about
saving lives.
Thank you very much.
JAMES ROBERTSON: Well Minister, thank you very
much for that important and interesting talk.