Health and Social Care Committee

We weren't, but—

We can give you an overview, if you like.

We can give you a quick overview each, which might actually give you more time for questions.

All right. I say a presentation—an overview, but that's fine. So, if you want to do that to start with, if that's helpful, and then we'll dive into some questions after that. Sorry, I should ask you perhaps just to introduce yourselves for the public record as well.

I'll just go and get my blood pressure measured. [Laughter.] I'm Jim McManus. I'm the national director of health and well-being.

And I'm Julie Bishop, I'm the director of health improvement.

Should I start, and we'll both do a double act and do, very quickly, five minutes? If I do the quick overview. I prefer to talk rather than using PowerPoint. I just find PowerPoint can be a crutch.

I guess the place I'd start would be imagine if we had done on smoking what we're currently doing as a world on obesity. Where would we be? You can look at some nations and you would see we would have many times the death rate we currently have in Wales. We would still have many times the amount of heart attacks, hospital admissions and cancers that we have, and we wouldn't have a smoking ban because we'd focus almost entirely on personal responsibility and on individual treatments. Imagine what the world would look like in terms of smoking.

I grew up in a mining village in Scotland where I think I was the only person in my class who didn't smoke. And, already, I'm one of five people of my age group who's not had an amputation and who hasn't died and who hasn't yet had a heart attack. So, I haven't won that bit of the Scottish lottery, as we called it in my village.

You can look back over 25 years of smoking control, particularly in communities like I grew up in, because my dad was a bus driver and my mum was a factory worker, and there are people alive today who wouldn't have been alive if we'd taken the personal responsibility message around smoking as our key and our only thing. I'm not denying as a psychologist that there's a role for personal action, but if that's the only thing, you're not going to get anywhere.

I think the other key thing is that there was no magic bullet for smoking. There was an accumulation of things—so, the smoking ban, we had smoking legislation, we are going to have legislation on single-use vapes, smoking in public places, the smoking age. All of these progressive things took persistent, consistent and insistent will and focus, and it's that on obesity—

Do you mind—? Jenny wanted to come in with a question.

Why are we repeating the same mistakes, then? Because the tobacco industry hammered Governments and told them not to ban it, so it took us 50 years, or something. We knew all about it, and we didn't—. So, why are we making the same mistakes with food?

I might get into trouble here, but it's partly because of the industry regulation, partly because I think we still think personal responsibility plays a role in health, partly because the food supply we have is now much more pervasively unhealthy and persistently unhealthy than smoking ever was. And I think it's partly because we've allowed this over 40 years to creep up in a way that it didn't with smoking—smoking was already there, whereas, with the food supply, it's crept up. And with the changing technology and lack of physical activity by default—we sit in cars, we drive to out-of-town shopping centres—we've basically changed our environment to engineer our food environment perfectly for preventable disease, in a way. I might be overstating it a bit, but it feels like that.

Actually, it's having economic consequences in terms of worklessness, and I don't think we've quite realised the impact of that, because we've been immersed in it as the water's gotten hotter, or I should say as the oil's gotten hotter. We're at the point where we want quick solutions. It's easy to think that personal responsibility and digital and tech will solve it. They have a part to play, but, actually, we need multiple things in there as well. Cancers caused by hormonal effects of obesity now exceed, in some parts of the UK, cancers caused by smoking.

I'll stop, I promise, by saying that, for me, I think there are five golden rules: there's no silver bullet; you need multiple layers of things, from the societal right down to the individual; you need a short, medium and long-term focus—you need to start by saying what will make a difference here, tomorrow, in a year, in 10 years, in five years; you need to be consistent—in a way, you almost have to burn the candle at both ends, both individual and societal; and we have to start with our food environment, to make healthy choice and physical activity by default consistent. So, those would be my rules, but the leadership is probably the key. Most prevention fails because the leadership and the focus stops after one or two years. Sorry, I may have taken too much time.

No, that's fine. Thank you, Professor McManus. Dr Bishop.

Just to pick up on that, and Jenny's question, I think one of the fundamental differences and one of the things that makes this much harder is that smoking is an individual, single behaviour. Obesity arises as a result of a multitude of different behaviours, so it's much, much more difficult. And the second thing is, of course, tobacco is the only product that, when used according to the manufacturers' instructions, kills two out of three of the people who use it. It has no redeeming qualities whatsoever. Food, unfortunately, or fortunately, is essential for life, so we can't do without food, and it's not—. It features in so many different parts of our lives; it's part of our culture, it's part of our celebrations, it's a part of how we show our love, and caring for people, so it's so ingrained into every part of our lives and our society. So, it makes it quite a lot more difficult to do. So, I think that's why it's a bit more difficult.

I think we do—. And I completely agree with the comments that Jim's already made: it is something that has crept up on us over time. Probably the main thing, when I was reflecting on this, is for us to think about where we are. We're all spending a lot of our time at the moment talking about the challenges of our healthcare system—it doesn't matter which bit of the UK we're in. We have a system that is unable to cope with the demand that faces it.

We are exactly where we said we would be. So, people like us, a few decades back, would have sat in front of committees like this, and so would a whole range of other far more august people than us, and there were lots of reports written that said we've got two problems: we've got an ageing population, and that ageing population is going to present really significant increases in demand, notwithstanding all the other things that have changed, and we need to fix the system that is going to need to look after those people. And the second thing that was said very clearly was, 'The burden of preventable disease is going to be overwhelming, and we need to focus on prevention.' And I could show you a huge stack of august reports and policy documents and strategies that said we need to focus on prevention, but we didn't actually do it. So, we are where we are because we failed to take a preventative approach.

You can take that view with obesity, where we're sitting now. We can look at the problem and we can say, 'Well, we'll just carry on doing what we're doing and we'll try and treat the problem', because there's an awful lot of people who do need treatment, or we can say, 'We're actually really going to focus on prevention and we're going to try and change things for the long term.' Because if we don't, the impact, potentially, of this problem on the health of the population and therefore the sustainability of our health and care services is really quite overwhelming. Sixty per cent of the population currently, adults, are not a healthy weight. The health consequences of that are already in train, and they are going to hit us over coming decades for those individuals. We're going to struggle to stop that, so we've already got a big problem. If we don't turn off the pipeline that is pushing more and more people into that space, then, okay, we might not be around as individuals to have to deal with it, but the legacy that we leave for the system will be quite significant.

So, we need to think about this issue differently and we need to use the—. We've got stated policy in Wales, through our Well-being of Future Generations (Wales) Act 2015, which is really talking about exactly this kind of problem. So, this is the point at which I think we've got to make some really tough choices, because the reality of the situation is that we cannot do it all. So, we need to think about where are we really going to put our energy, where are we going to put the resources that we can find in the system, and have that focus on where we want to get to in the longer term, which has got to be about tackling some of the issues that Jim's highlighted around the underlying causes, not treating the problem.

Thank you, both, for the overview, and thank you also for the comprehensive document you sent us ahead of this inquiry as well. There's a sentence in the evidence that you sent us that also backs up a lot of what you've just alluded to now. What you said in the paper was:

'Many of the changes needed to address obesity require responsibility and accountability across organisations and sectors and oversight to ensure that they are held to account to support change.'

And I suppose the fact that you've written that, and what you said, Professor McManus, perhaps implies that that's not happening now, and I think, Dr Bishop, you said in your opening as well, 'We've had these policies before, and they've been published, but we haven't done them.' So, perhaps you could talk to that point from a Wales perspective, and what more needs to be done, in terms of holding organisations to account.

I think, if any nation in the world, and I'm not being sentimental about Wales at all, but if any nation in the world could do it, it's Wales that could turn the tide on this.

Why is that? Why is that?

The health of future generations Act. I think Government, Ministers, Assembly Members get whole-system approaches. I don't want to be rude about Westminster, but there feels to me a much stronger and more direct connection between the citizens of Wales and our Government, and so all of those key political conditions that mitigate for activities are already in place. So, there's already a foundation from which we're starting. Free school meals and school meals is starting as well. What you now need, I think, is one version of the truth of what's going to make a difference. Stop endlessly redescribing. Somebody published a report yesterday, in The Lancet I think it was, on how green space is good for your mental health. It's like, 'Oh, I haven't read that 900 million times in every medical journal ever.' So, we need to stop redescribing the problem.

And then you need leadership. I know that several UK Government departments are working closely with people like Mariana Mazzucato in terms of mission-driven Government—the idea of a clear mission around what is going to change, who is held to account, what is leadership. So, we need to describe, in some detail, 'You as an agency are responsible for this, and you will be accountable to whoever.' That, I think, is where we need to be really held to account for what we're delivering. So, it's clarity of what we do, it's accountability of what we do, it's having to account for delivering the best value for money. So, every penny should be spent. And, on that point, I would say that spending lots and lots and lots of money on weight-loss drugs for the entire population is just investing now to spend even more two years down the line.

But, just to get back to the question, I suppose—

Sorry.

No. What you were saying in your paper is that organisations right across the sector, these organisations all need to be held to account, which backs up what Dr Bishop said, that we've had these papers before, and we haven't delivered. So, what more needs to be done? What needs to be done to change that?

If I could wave a magic wand, it would be Government setting up a board that it publicly held to account and was held to account here for what we deliver and given very clear delivery.

Aren't those structures already in place?

Yes, they are. We could have this conversation about lots of different things, because I think the challenge that we've got is that the mechanisms by which Government holds different bits of society to account are quite different, aren't they? And one of the challenges anybody working at a local level will tell you is that one bit of the organisation is told to do this, and another bit of the local system is told to do that, and somebody else is focused on something else. And whilst they can do a certain amount by coming together, and obviously we've got examples of partnerships—public services boards, et cetera, that are trying to do those things—if they're trying to also meet another set of requirements, and then you add the fact that everybody is struggling, because of the cost and financial pressures, and our public services are in a difficult place, it's quite hard to focus on coming together to do those things.

So, what needs to change then?

Well, I think there are two things, because we do have a national implementation board. But what we don't have is a clear set of measures about specific outcomes that we want to see. We've been working on those, and we're helping to develop them at the moment, and the challenge is, going back to the earlier point, that there are lots of them. So, I think there are probably two things that we need to do: work out, collectively, which ones we're going to go for first, so that we put the energy of the system into the same things, as opposed to spreading ourselves across lots of different ones; and secondly, make sure we've got the clear metrics in place that show us whether or not what we're doing is actually bringing about the change that we want to see. And the outcomes framework that we've been working on would be usable in the sense that it would be clear which bit of the system needed to do what.

Okay, thank you. Mabon, did you want to come in on this point?

Yes, very quickly. Your contributions have been very interesting. And although this is the health committee, it’s clear that obesity isn’t a clinical problem—it’s a social or sociological problem. I struggle with the argument about personal responsibility. We accept that people need to take personal responsibility, but we know that obesity as an epidemic is related to poverty. People who are in poverty can’t make the decisions that someone who is better off can make, they can’t make healthier meals or take exercise when they need to be at work, et cetera.

So, what do you think, beyond that clinical element—? What policy do we therefore need to look at that will address obesity, socially and sociologically? I’m thinking specifically about the child poverty targets and so on, and addressing those elements. What are your opinions on that?

Do you want me to start? I agree with you that personal responsibility is only a sliver of the issue, and it will work most for people who have most resources, including the most education and money. And we’ve seen that in everything. What we need to do in very poor areas is look at the food choice. So, if your takeaways—. I used to work in Birmingham, and takeaways are much cheaper, often, than healthier food. I think there’s something like a £5 difference per 1,000 calories for healthier food than unhealthy food, as we’ve alluded to in the paper.

So, we need to make healthier food plentiful, easier to get, affordable. We also need to support people in being able to cook for themselves and being able to have nutrition that isn’t dependent on factory processed foods for the bulk of our food. So, there’s a skills element, there’s a fuel affordability element, there’s a minimum wage element, there’s a poverty element. Feeding children at school will go some significant way to doing some of that, but then addressing minimum wage, zero-hours contracting, as you say, there’s a whole—. It goes back to what Julie said about multiple consequences and multiple causes. The capabilities to eat healthily systematically need to be addressed for our poorest populations, and that’s about money, it’s about disposable income, it’s about food accessibility.

Not so very long ago, I visited a project in Ely that was run by the probation service, who were looking at drug services, and the thing I noticed—I went on bus and foot—was, for the availability of healthy food in that whole estate, you have to get in a car to get there. And I could say that about where I grew up, and I could say that about multiple places. So, those are the factors we have to start addressing.

And you could write a checklist of them. I’ve mentioned several, which I think are the biggies. Some of them are short term, such as minimum wage; some of them are much longer, such as policies on the saturation of takeaways. Some of them are much more long term, such as teaching children to cook, so that they can cook for themselves and be dependent on themselves. But you can do it.

You mentioned short term. Perhaps, very quickly, just tell us—because much of what we’ve spoken about is long term, that will take longer to achieve—what are the short-term measures that could be taken to address obesity?

I think I would focus on the early years, (a), because that is the prevention bit, and (b), because, if we get it right, we can make a lifelong change. And some of the things we need to do in that space are going to be difficult, like changing the culture around breastfeeding compared to infant formula. But there are others that shouldn’t be as difficult, and we have an infrastructure in our health visiting, school nursing, midwifery services—and they are challenged at the moment—where we should be able to make a difference, if we get that bit to work. And it’s measurable.

The added benefit is that we know that getting that bit of the system working right isn’t just going to help us fix this problem; it’s going to help us fix an awful lot of others as well. So, that’s where I would put the energy.

Okay, thank you. Joyce, you wanted to come in. I’m just conscious—just be careful—there are other people who want to ask questions, so don't overflow into those, Joyce.

I agree completely, and the point I would make is this: if you go into a hospital in Wales and you want to buy food for yourself because someone's in hospital, you're going to be met with Costa. So, you're going to have lots of cakes and lots of unhealthy food. I know because I've been visiting someone in hospital recently. There's no other choice. That is our health service. So, we've got to make the changes in the right place, and that is obviously the right place for me.

Shall I ask my question about mental health now?

If you want to, Joyce, yes.

There's a clear, established link between mental health and obesity, and I would argue that it comes from societal norms about comfort eating. We hear that phrase all the time. So, how do we address those, and is there enough of a focus on it?

There are a couple of points I would raise. In terms of healthy food environments in hospitals, when I had cancer, the choice was what you got in the hospital or Burger King. And it was a big teaching hospital, where I went for my cancer treatment. So, we could make a difference in hospital food environments and we could also ban price promotions to add to the list of things that would be not quite as short term as Julie—. That would be more short to medium term.

But, in terms of mental health, I think you've got multiple mental health issues arising from obesity. One is people comfort eating because of stress, and we know that those nations that have really tackled workplace stress or life stress and giving people life skills have better mental health outcomes. I think we know enough, actually. Comfort eating is almost self-medicating—we've all done it, I'm sure; I certainly have—in terms of dealing with mental health or stress. And we saw it during lockdown. We talk about lockdown lard. So, there are things that employers can do, there are things that schools can do to build resilience skills in the population. We know that they work, we know that they're effective. We also know that workplace mental health skills really help people across their life. Social connection is another important thing. So, we know that if people get into volunteering or social connection, then that can really help as well. There's no quick fix for the mental health impact of it.

And then you've got the mental health impact on people who are living with eating disorders or people who are living with just being overweight and feeling the stigma of it. And it's almost as if there is a second epidemic of mental health issues, which is actually partly driving our food intake and partly coming of it. There's no quick fix, but there are things that you can do that will make a dent, like employer well-being, like resilience in schools through the whole-school mental health approach. There are things that you can do; it's just being realistic about the timescale in which they change, if that makes sense.

I agree. We're looking at it on a number of fronts at the moment. So, the point about stigma is an important one. At the moment, that is probably one of the single biggest barriers to us tackling this problem, because we're at a point where you almost can't talk about the issue. Health professionals are even frightened to raise the issue of weight with their patients because of the reaction that they get. And that is very much to do with the stigma.

When we developed the Healthy Weight Healthy You digital tool, we did a lot of research and we looked at what we call people's weight journeys, and there were two that came through that were really clearly linked to mental health. One of them is what Jim has talked about, where people use food as a means to influence their mood. And it's not simple, but it's just helping people to really recognise that that's what they're doing and develop alternative strategies. So, one of the things that we've launched this summer is our Hapus initiative, which is about encouraging people to take healthier ways of addressing their mood and well-being. So, that's a positive strategy. Instead of normalising comfort eating—the point that you're making—it's actually us all being part of saying, 'Well, you could do something else that would actually make you feel better.'

And, obviously, the other one involves much smaller numbers of people, but the people who have experienced psychological trauma, and we know that there is a very clear relationship between that and obesity. But that requires treatment for the underlying disorder. That's actually a mental health problem, not a food or nutrition-related issue.

I think the other point I would quickly make is what we've got to be really careful about is not allowing concerns that people have got about eating disorders to stop us taking population action on healthy weight. Eating disorders are devastating for individuals and families—they're awful, particularly something like anorexia—but it is a tiny proportion of the population, and talking about healthy eating or being a healthy weight does not cause somebody to develop an eating disorder. That comes from a complex set of mental health and personality attributes. So, both require our attention and both are important, but we mustn't let one stop the other happening.

Thank you.

Jenny, I'm just conscious that we might go off our subject area, so—[Interruption.]—just a very quick one, yes.

How long has the national implementation board been meeting and why is it that you still haven't come up with what we need to do, given how urgent this is?

I think we've had it in place in slightly different guises, certainly for the last delivery plan, which was for two years. There are a number of different things happening at once, and I think my reflection, having been part of that, is that it's probably trying to do too many things at once. So, the delivery plans are not focused, they're not based on outcome measurements. We're not sitting down and saying—and, you know, I've been involved in the process—we're not sitting down and saying, 'Right, over the next two years, we are really going to put our energy into this one and that one, and we're really clear what everybody needs to do about it.' We haven't got to that level of granularity and some of that is because, I think, when the Government published 'Healthy Weight: Healthy Wales', we were literally, I think, still in the pandemic. The timing was not good, and that had two impacts: obviously, all of the public health professionals who would be key to actually helping to take this forward were really doing other things, and, obviously, the system was struggling to recover. So, I think we had a very difficult start for the process, and whilst I think we've got a very, very good strategy, one of the things we have been working with our Government colleagues to think about is the implementation bit of it needs a lot more focus.

Okay. I'm just conscious that we've got a lot of subject areas to cover. Altaf Hussain.

Thank you very much, Chair. I am conscious of the time, and I'll quickly go through my only one or two questions. My area is the 'Healthy Weight: Healthy Wales' strategy, which you touched on earlier. What progress has 'Healthy Weight: Healthy Wales' made so far, and are the priorities set for 2022 and 2024 being met, and is there any problem with the funding?

So, I think, in progress, quite a lot has been done, so we've established whole-system approaches to healthy weight projects across every region of Wales, which is, under the leadership of our directors of public health, bringing the local systems together to agree what priorities they're going to work on. Building that infrastructure does take time, but we are starting to see that really starting to achieve what we expected it to.

We've developed and published an all-Wales healthy weight pathway, and that's now in existence. We have a set of metrics that will help us measure the impact of that, that are about to be rolled out across the system, and there has been, compared to the original review that Public Health Wales did about our weight management services, where basically we had almost nothing anywhere in Wales—I mean, we've got a tiny amount at the moment, but we do have some—and we have made progress from that perspective. And we have done a great deal of work in terms of the food environment legislation proposals that the Government consulted on. That's just to name a few.

So, I think it wouldn't be right to say that we haven't made progress, because, actually, I think there has been quite a lot, but, equally, there is a lot to do, when I think we collectively started on this journey—I think Jim alluded to it earlier—one of the things that Public Health Wales was very keen to emphasise was that it's going to take us at least a decade before we begin to see any kind of change, because that's what the international evidence told us. So, there is a need to build for the long term in order to actually see the outcomes that we're trying to change in terms of healthy weight and the weight of the population. We can see change in some of the other outcomes that contribute to that before then, but, ultimately, it's going to take a while.

Altaf, do you have further questions?

Yes. Thank you very much for that. And I'll ask my last question, Chair. We talk about data collection. Are any improvements needed to the way data on being overweight and obesity is collected in Wales? Now, my point is that I have gone through these papers and I have not seen anywhere being mentioned obesity as to central obesity or abdominal obesity, or you can say 'potbelly' or 'a beer belly', which does increase the risk of serious health problems. Also, I have not seen—the second point, really—the ethnicity. We have forgotten about that. Of the black population, 70 per cent are overweight. We're not seeing the Asians who come with these potbellies. I really would be grateful for your opinion on this.

Okay. I think there's a number of different issues around data, and that is one of the things that we have been working on. Most of the data we have on the adult population of Wales comes from the national survey and is self-reported. It's okay, but, clearly, there are limitations to that, and we know that is going to be a massive underestimate. It doesn't enable us to measure things like central obesity, which we know is helpful. So, one of the gaps is about routine and regular clinical management and monitoring in primary care, which needs to start to look at, basically, measuring around people's waists, as well as putting them on the scales and measuring their height. That's something that we don't have happening.

I don't think there's any set of statistics that we look at as public health professionals where we have the data we would like to see on things like ethnicity. It is very, very poorly recorded in almost every aspect of our healthcare system, and it's something that our colleagues, I know, are working on in terms of trying to address that. You've mentioned a couple of population groups where the thresholds by which we see harm is actually much lower. So, if you look at the pathway, it's very clear that the thresholds at which you take action for populations from certain south-Asian or black African or Caribbean backgrounds are lower, because the health consequences they start to experience happen at a lower level. It's absolutely fundamental that we understand that those population groups are being supported and helped, because they will see the consequences much more significantly.

Thank you, Altaf. Mabon ap Gwynfor—

No, I think Jim wants to address the abdominal obesity.

Sorry, I missed that.

I got half of it, which was addressing abdominal obesity.

The abdominal obesity issue is, essentially, that we recognise, because of the complex way in which obesity causes problems, that if the fat—. If you're an apple rather than a pear in reality in your shape, you're much more likely to suffer health problems as a consequence of it. So, one of the things that have been recognised now is that—this is more at an individual than a population level—when clinicians are looking at their patients and they're looking at their weight, they also need to consider the extent to which that is centrally located, because the risk is much higher. So, it is another thing that we are having to think about in terms of how our primary care and our clinical professionals look at this particular issue. It's not happening at the moment routinely.

Sorry, have you asked all your questions?

Yes, thanks, Chair. Yes, because you see more complications and you see more deaths with this type of obesity. Thank you very much.

Thank you, Altaf. I know Mabon's got the next set of questions. There's a quick question from John and Jenny. John.

It is a quick question, Chair. Just in terms of ethnicity, we found, during the pandemic, locally in Newport, which I represent—the eastern half, anyway—working with Muslim Doctors Cymru was really, really good, because they understood the community, they were part of the Asian community, and they organised vaccination sessions in the mosques. They're now doing a lot of health checks and some health delivery in the mosques and other community settings. I just think that's one obvious way of reaching out to that particular community, and, hopefully, there are similar ways for other minority communities.

I couldn't agree more. The more voluntary action you get going, the better. Absolutely. And they've been heroes during COVID.

Jenny, you wanted to come in as well.

Given that we know that the girdle, the abdominal measurement, is a really key indicator of the risks that people are carrying, why don't we simply ask our health professionals just to measure people's waists? They only need a tape measure, not an expensive machine.

I know that that sounds like the easiest thing in the world, doesn't it? Unfortunately, it's really quite difficult. I think there are lots of reasons for that, and those of us who spend our lives trying to influence the practice of different professionals to do different things can tell you that it takes a long time—there's been an estimate, in some cases, of up to 17 years—for a new scientific piece of knowledge to actually become routine practice on the ground. So, NICE changed their guidance, which should be the basis that actually gives all clinical professionals an understanding of what good practice looks like. So, they've been given clear guidance about where central obesity should be measured. It's actually—. I know it sounds quite easy, but it's surprisingly difficult to get it in the right place. It's much more invasive, so I think there's a bit of discomfort—you know, if people are feeling uncomfortable about asking people to stand on scales, then there's probably an extra level of discomfort about asking them to roll up their clothes and have their waist measured. So, you're right, it's not something that requires a lot of technology, but it's one of those things that we've actually systematically got to look at as part of a wider initiative. But, in reality, at the moment, there is nothing that requires or incentivises our clinical professionals to measure anybody's weight at all. So, we've got to get that basic architecture in place and then think about how that's actually happening.

And now Mabon.

Sorry, I'm going off piste here, Chair, but could I take you back? Dr Bishop, you made a point in the discussion on ethnicity earlier in terms of data and the lack of data. I have to be honest, I'm very fed up of all the consultations and inquiries that we do and, every time, when it comes to health, there are complaints about the lack of data. Now, the one thing I don't understand about that is that we have in Wales the most valuable databank in the world—the SAIL databank. We have a load of information there, so why are we so bad at gathering the data in order to tackle this? What is the weakness in that system that prevents us from gathering that accurate data?

You're right, SAIL is a marvellous tool and it's got potential, but it's only as good as what goes in, so it's that kind of 'garbage in, garbage out' scenario. So, because this is not routinely measured—. We tried to do a piece of research, actually, to understand, if you looked at clinical records across Wales in primary care, how many people have had their weight measured in the last two years, for example, and it had been recorded. We had real challenges getting permission to do that. But UK studies in that space have shown that it's not actually done very well. So, whilst SAIL gives us a mechanism to look at the data that is there, it doesn't provide the data input in the first place.

So, is that a policy question for us—that we have to look at ensuring that health boards, in terms of primary care onwards, have a single system of gathering data and make it a policy point to gather that data, and that, every time a patient goes in, they gather that kind of information? Is that something that we should look at?

Yes.

Yes. If you take the eight basic care processes for diabetes, there are some areas that barely get above 40 per cent, which means that only 40 per cent of people with type 2 diabetes that we already know about are getting checks that will stop them ending up in hospital. So, I think your idea would be very sensible.

If you look at Jim's earlier analogy about what we did for smoking, we incentivised and required GPs to ask people, 'Do you smoke?', and then to start to do something about it. We need, basically, to take the same strategy with weight.

Could I ask one further question on news that has emerged during this week about Wes Streeting, who made an announcement in England that he wants to give jabs to people in order to get them to lose weight. Do you think that that's the kind of plan that would have an impact and influence people? Dr McManus, you mentioned previously that there is not much point in giving people medication or drugs because it does delay the problem. Is Wes Streeting's solution an actual solution to this?

So, for me, there's no doubt that treatment has a place in a pathway, if you think about the pathway and get the pathway properly done. So, for some people, and NICE has given guidance around that, this will have a benefit. But most people who take Wegovy—sorry, that sounds like a Scotsman calling on Michael Gove, doesn't it? Wee Govey. Sorry. [Laughter.] Other drugs are available. Most people who go on these drugs put the weight back on because their food environment hasn't changed, their capability and their motivation hasn't changed. You can only go on them for two years. It's very expensive. It really is very expensive. If you do, particularly, some health economic analysis on the cost-benefit curve and the lifetime-benefit curve, you are looking at some of the most—. This is at the high end of affordability for outcome—cost per DALY, for example—if you factor everything in.

There are potential side effects. There are system consequences, because people with diabetes can't get them. We know that, for people who have got lots of fat on their liver, these drugs can be beneficial in terms of reducing inflammation and removing fat. But, if they can't get them, will it drive up the number of people who go on to develop liver disease that's avoidable because, actually, they can't get them?

So, for all of those reasons, you can't treat your way out of obesity and give the entire population—. You wouldn't ethically want to medicate an entire population anyway, would you? That would be unethical. So, it has a place, but it has to be a very clearly discerned, sensible place in a proper pathway, and it's not going to solve the problem. Because, in two years' time, you are going to have an awful lot of people coming off Wegovy or other drugs, putting the weight back on, and they will be exactly back where they started, and all we have done is delay the wave of ill health.

It's a little bit like using the smoking analogy again. We don't provide smoking cessation services to reduce the prevalence of smoking in the population. We provide smoking cessation services to save people's lives, because smoking kills people. So, it's relevant at the individual level; it's not relevant at the population level.

So, there will be people, particularly those who are already developing another health problem that is related to obesity, for whom this will be the right kind of treatment for them. But there is an unbelievably sophisticated comms campaign that has been running for a good couple of years now, because you cannot pick up a magazine or a popular daily newspaper where there is not an article about which celebrity or some other person has actually benefited from these drugs. So, they are doing what they always do, which is driving up public demand.

What we're seeing in our already stretched weight management services is that they are being besieged by people who want access to these drugs. So, finding our way of navigating through this problem is something that we're going to have to deal with. But I think that, for me, it goes right back to what I said at the beginning: this is our test moment. Do we throw an enormous amount of the NHS budget at drugs that are not going to solve the problem in the long term, or do we put our energy and resources into prevention?

And I think, if I may, Chair, that there's a really good question—. The question, for me, that you asked is: will this reduce, stop or delay the preventable health consequences of obesity? All it will do is delay. It won't stop or reduce. It might make a dent in it for a small number of people who come off it and also have the dietetic advice and the psychological advice and everything else that goes with it in the pathway. But if you just chuck a drug at people—you know, it's not paracetamol.

Thank you.

John. John Griffiths.

Diolch yn fawr, Cadeirydd. Locally in Newport, going back a few years, I brokered meetings between the sport and activity sectors and the local health board, the public health arm of the local health board. We had a number of meetings and everybody saw the sense of being more preventative, but we could never get any money out of the health board, basically, for any initiatives that might have come out of the joint meetings. So, I think, because the health sector is, basically, coping with what comes at it and the demands are so great, it’s quite difficult to get their heads above the parapet really and look at the more longer term preventative agenda and work with partners that can deliver on that. I’m still trying. We had an Active Newport event that I organised the other week. I’m still hopeful. But do you see any signs of that sort of situation not continuing? Because one important aspect of prevention is to get people more active, physically active, isn’t it?

We do the same at a national level. We recognise exactly what you’re talking about. When we look at prevention, particularly in the health of the population, and we were talking about things like what we call the wider determinants earlier, almost all parts of society have an impact on the health of the public. If we take the view that it is the health system’s job, therefore, to fund those activities because they’re good for health, that sets up a very strange kind of way of looking at the world. It’s probably better for us to be saying, if all those other sectors do what they’re there to do as well as possible, society as a whole benefits, because it will have a health benefit.

So, with things like physical activity, one of the challenges is that different people will choose to be active in different ways. One of our biggest challenges is actually motivating people to want to be active. Because, actually, you don’t need anything in terms of equipment or materials to be active, you just need to use the—. Even if you’re a user of a wheelchair, you can still be active by just going outside and walking somewhere. You know, it isn't—. Sport has got all sorts of benefits, and I’m certainly not suggesting that’s not a good thing for society, but we need to be careful not to give the impression that you can only be active if you’ve got a leisure centre or a swimming pool or belong to a sports club. One of the recommendations that we’ve been making is that we just need to, collectively, get Wales walking.

Yes, I'd agree, and I think there are things you can do without money. You’ve got an awesome director of public health, Tracey, and I’m biased because I’ve worked with her before, but she’s fab. But if you just get—. The voluntary sector can do so many different things. Actually, faith groups can do huge amounts of things. There’s a thing in various places called parish nursing, where they will have nurses who will do it. What can you do without money? What can you do with what you’ve got while we build the coalition for doing it? One of the things that civic society can do that the NHS can’t is change social norms, for physical activity to be default and for us to look after ourselves and each other. So, I would say, ‘Keep going’, because I’ve heard of what you’re doing. I know that we’ve got a programme called Shaping Places for Well-being in Wales, which has got every public services board signed up. The problem is, there’s no money. So, what can we do without money? We can create a movement, can’t we? We can energise people. We can empower people to think, ‘Well, I can do that.’ And if you get people doing what they can do without money, you’ll still make a big difference.

I think one good example of that, Cadeirydd, as a voluntary movement that’s really contributing on this agenda, is parkrun. I’m pretty parochial, I talk about Newport a lot, I know, Chair, but there are two parkruns in Newport and very often 700 people are out on a Saturday morning running or walking, and they very much emphasise walking now. There are people in wheelchairs. There are mums and dads with prams and the little ones in there. There’s the volunteering and the social connection. They do Couch to 5K, and there are quite a lot of people who were carrying quite a lot of weight who’ve lost that weight in a sustainable and progressive way over a period of time. It's quite phenomenal, really, and, as you say, you don't need to spend much money. But I guess, if I'm honest, we don't see many members of the ethnic minority communities at the parkrun, and it probably is quite middle class. I suppose the challenge is to build it and develop it even more in the way that reaches across communities, really.

You need champions in those communities, don't you, to take it into those communities.

My dad went for gardening and golfing. You would never have seen him near running. And he didn't like football, which is unusual for a Scot, I accept. So, what can entice different communities into doing different things? That's the key thing, and working with those communities.

John, what was your personal best? [Laughter.]

Twenty-one minutes and 51 seconds, Russell.

Really? I've just done my third parkrun, actually; I did it the other week in Newtown. But I've got some catching up to do with you, John. [Laughter.]

I'm not doing those times now; this was several years ago, Chair.

Just a couple of other questions. I think the way that we try and reach into—. As we heard earlier, there's quite a link, isn't there, between relative deprivation and obesity. You've touched on it, and we've touched on it in the discussion already, but in terms of more active environments and environments where making the right food choices is easier, is there anything in particular you would point to in terms of what needs to be done in those communities? Are there any obvious things that we could be doing better than we are at the moment?

It takes time, but one of the things you could do is actually look at the areas that are worst affected, do a local audit, and then develop a local action plan of what you can do about food supply. That's micro level, and I think you have to do that.

I think the other thing is energising local communities, and working with them—that's another thing. That takes a while, but it's really worth it. It's about sitting in supermarket community rooms at 9 o'clock at night discussing food supply with citizens. After two years' worth of hard effort, they will run and they will do more than you could ever achieve, in my experience of doing that with them.

I think the other thing is give local authorities powers to regulate food supply in their areas; give local authorities teeth. The local government is the placemaker of our local area, and the custodian of our local area. And I was in local government for most of my life. So, give local authorities powers.

Ban price promotions and the incentives that make it easier to make unhealthy food supply the default choice. And actually, I know you've got Cardiff and Vale College coming. I don't know if you've seen it, but they did a video up a street—I can't remember which street it was—and every single bus-stop advertising boarding in a 300m radius was for really unhealthy food. It's treat food, but it's not treat now, it's default. Ban that and make those changes, because those, like gambling shops, are saturated in poorer areas.

We've held two big events, bringing together planning professionals working in local authorities and public health professionals to talk about some of these kinds of issues, and there are quite a lot of things we can already do, but there are some gaps in our regulatory system. There are certain well-known fast-food chains who are really aggressively challenging any attempts by local authorities to stop them opening, for example, near some of ours schools. The fact that they're willing to spend the money to go to court to fight those things tells you something about what they perceive the benefits to be. And, of course, for our local authorities, the cost of actually defending that kind of thing is a real barrier to them actually standing up. So, anything that we can do that actually protects local authorities from having to go through too many legal hoops in order to do what actually they want to do, to be fair.

And then the other thing that we've been looking at, talking about the data earlier, is we've actually got the data for this. We know where those things are, we know where the food deserts are, we know which communities don't have access to a green space, a play area and all those kinds of things. If we use that data, that really helps at a local level to see where do we need to put our energy, picking particularly those areas of more disadvantage where children are less likely to have access to green space. Just giving them that makes a massive difference to whether or not they're likely to be active.

Chair, perhaps just one more question, on the draft Food (Promotion and Placement) (Wales) Regulations and the recent consultation. What joint working has been established with the food manufacturing and retail industries in relation to how the production and sale of commercially produced food and drink can impact on obesity levels? I'm interested in this because it's really important in terms of the way the food industry operates, which is awful, I think, in many ways, and what levers there are to do something about that. I guess we're pretty limited in Wales in terms of the devolution settlement, really, aren't we? So is it more about trying to establish joint working rather than wielding the stick, as it were?

When you look at the international evidence in this space, it's even challenging for the UK Government to act, because in essence the food we eat is controlled by a small number of major global conglomerates that are almost outside the regulation of any government, and that is part of the challenge that we face. Obviously, in terms of the food environment regulations that are proposed, we've worked closely with Government on that, and we're strong supporters of it.

We've had the experience of the responsibility deal that was implemented by the previous UK Government, and there were some benefits to that, but what we can see when we look internationally—. The sugar levy is a good example. Many countries have done that. What we've achieved by regulation went far further than any voluntary agreement ever has, and I think what we're already seeing, and saw from the wider food environment regulations that have been implemented in England by the previous Government but that we’re also talking about in Wales now, is the industry responding, because they can see regulation coming. I don't know a single expert anywhere globally who won't tell you that the answer here is only in regulation, and the state needs to step up and level the playing field for people. Because these big companies are so big and so powerful, it is really difficult to do it any other way, and although that might be sometimes unpalatable, it is probably the only way we're going to change anything, because it's those things that have created this problem.

Even just simple things like—. There are multiple examples, but we've done quite a lot of work on things like meal deals or whatever. If you go and buy lunch in any shop now, you cannot buy a single packet of crisps that is not a grab bag of 40g. Most of us are old enough to remember when crisp packets were 25g, and if you buy a multipack of crisps that's the size you still get, but it is impossible to buy a small bag of crisps as a single item. That's not something any member of the public asked for. That is something that the industry did because it means they sell more crisps. So those kinds of things, the supersizing of products, for example, are the sorts of things that we have to tackle, but unfortunately we are going to have to require the industry to do that. There just isn't the incentive for them to come there willingly.

Thank you. Just to give some indication on time, we'll go over a little bit on this session, but even with that, we've just got 15 minutes left. Assuming Joyce has covered her subject areas, there are three subject areas left to cover: Jenny, and then John, and then Mabon finally, so that allows about five minutes for each subject area. I just hope you don't mind if the Members interrupt just to get to a point on something as well. Thank you very much. Jenny.

Thank you for your paper, which is comprehensive and tells you the size of the problem and our failure to act earlier. You say that, as a priority, we should ensure that public sector food provision takes action to reduce—you say ‘reduce’—the use of ultra-processed food, particularly in the school meal system. Why have we not banned UPF in all our public sector foods?

A number of reasons, I think. If I start, the first one is, I think, that the understanding of the impact of UPFs and what they may be contributing to this problem is still relatively new knowledge. So I think that's the first thing.

I'm sure caterers would quickly understand it—

I agree. The Scientific Advisory Committee on Nutrition, which advises all of the UK Governments on nutrition policy, looked at this issue and they did not make recommendations to restrict ultra-processed foods. I personally, as a professional, think that was unwise. I understand why they didn't—

This was in the last UK Government, was it? They were probably instructed not to do that.

I understand why they did that in the sense that whilst the epidemiological evidence, the kind of stuff that Jim and I look at, is pretty compelling—there is a clear relationship between these products and health outcomes, and particularly obesity—the exact mechanism by which they do that we don't really know. I personally think we should be able to act without fully understanding the mechanism. One of the things that I'm sure you know is that the Government is looking at revising the school food nutrition regulations, which are quite out of date now on a whole number of issues, and one of the things Public Health Wales is advocating for, and will continue to advocate for, is that it makes reference to ultra-processed foods.

You say that the food-based standards in schools are complex and do not meet nutritional requirements. I appreciate you've put a caveat in there, but I absolutely would agree with that. So, why are we spending £600 million on something that doesn't meet nutritional requirements? It doesn't even measure what children eat; it just measures these different menus and it doesn't measure what goes in the bin. It doesn't do any of the things we really need to know.

I agree.

So, what is stopping us doing this, given that, at the moment, the Cabinet Secretary doesn't intend to introduce new regulations until 2026?

You will know it takes a while to get regulations through. They've got to be properly considered, they've got to be tested, you don't want to be changing them every five minutes. We're in favour of a considered process that makes sure that we get them right, but there are different stakeholders here. There are challenges between the providers of school meals and there are people like ourselves sitting there saying, 'Yes, but the health of the population is more important'.

We've got to consider both of those things, haven't we? We've got to consider the achievability of implementing standards as well as what we'd actually like them to be. So, the approach that Public Health Wales is advocating for, as you probably would expect, is that we shouldn't be shy on the ambition we have for the health of our children. So, we should be setting out what the nutritional science says children should be getting. If we have to have a phased process of implementation, because, logistically, it will be difficult to do—.

One of the examples—they certainly did this in Scotland—is that we know where we are on sugar and where we need to be meet the current nutritional requirements for children is quite a big gap, and changing that overnight is going to be difficult because we're going to need the suppliers to change to reformulate their products, and all those kinds of things.

But what we are very concerned about is that we don't frame the regulations based on what we think we can do as opposed to what we think we should do. In the primary sector, I think it's really straightforward. You're giving a child a meal, you can calculate the nutritional content of that meal. It's either meeting the guidelines or it isn't. The complicated processes we have now about what day of the week it is and how many of these have you—. I mean, it's quite bewildering at times.

The secondary school environment we think is much more complex and it requires a bit of a root-and-branch review, because the current way that we look at the regulations isn't actually delivering what we need it to.

At the moment, caterers are basically targeting people with all the things they're doing in the commercial sector, which is they give you the sugary options, the bottles of water when it should be free. And really, it's our fault that we're not doing something about this.

You said earlier that you think we should start in the early years, and it is true that in the nursery the child is presented with a meal, and then they're encouraged to taste everything and that works really well. And then, we move on up and it gets more difficult. How much conversation have you had with educationalists about embracing food in the new curriculum? Because there are lots of things you can learn, about mathematics, and science, et cetera.

Absolutely. In fact, this afternoon, I'm going to meet with some of my team who've been working with teachers across Wales in the context of the new curriculum, to develop a curriculum toolkit on food and nutrition for those very reasons. So, there is a lot of work going on at the moment to think about how we can strengthen the teaching and learning with respect to food and nutrition in our schools, and, obviously, our current curriculum provides the perfect opportunity, through the area of learning and experience for health and well-being, to do that. But it is an area that's been neglected, and it's an area where, particularly in the primary sector—. Secondary schools still have people who've been trained to do that kind of thing—one or two of them floating about. But, in the primary sector, it's a bit like physical activity, it's the same challenge: the confidence of the teachers to do those things, the equipment, the facilities, sometimes, are a barrier. But we would say that, in the same way we won't medicate our way out of this process, we won't educate our way out of this process either. But the one area where we should put a focus on education is in our schools—it is a natural place and a life skill that children should have. Every child, in our view, should leave school being able to prepare a standard range of healthy, cheap, affordable meals. Why would you not do that?

Okay. So, my final question is: just as, in the health sector, you find people who are reluctant to measure people's waists, et cetera, we also have people in the education sector whose diet is a disaster zone themselves. So, how are we going to get—? We're not going to get people saying, 'Oh, why don't you try that bit of broccoli?', if they think that broccoli is disgusting. This is a really complex field, but, as with depression, getting people to ask people about their depression, you have to—. It's training, isn't it?

Yes. And it's something that's going to happen over generations. One of the reasons people in this country don't like vegetables is because they're often cooked awfully—

Yes, totally.

—and it puts people off, doesn't it? That bit, which is changing our palate, if you like—I can't think of a better way of putting it—to encourage people to be more experimental, to eat a broader range of things, to be a bit less conservative about, 'What's that? That's not brown, beige and fried, so I'm not going to eat it', is our biggest challenge. And it is not an overnight issue that we're going to work on. To be fair to the school meals system, one of the issues is there's no point in us putting meals in front of children that they will end up in the bin, and we've all had the anecdotal stories about the challenges of that. So, that phased process to develop from the next generation is really important. And schools have got a really important role to play, particularly those in more disadvantaged communities, where children, because money's not available, haven't had the same opportunities to try and see and learn about food and where it comes from.

Sure. Thank you. John Griffiths.

Diolch yn fawr, Gadeirydd. If we move on to weight management services, do those currently in place in Wales have enough provision and capacity, do you think, to meet current needs and demands, and to make sure that waiting times are not too long? And is enough being done to achieve equity of service across Wales?

No, if you want a really short answer. [Laughter.]

A short answer.

That's good. Next question, John. [Laughter.]

On all of those things, I think we'd probably say, 'No, they don't.'

It comes back as well, doesn't it, to the balance you mentioned earlier, really, in terms of, as you said, where do you put the focus: is it prevention, is it providing—? So, how much of a problem is it that you've answered 'no' to that question, would you say?

And what needs to happen?

There's a big policy choice here, isn't there? So, with our NHS, which does wonderful things, are we here to treat every single thing, or do we want a healthy society? And if we want a healthy society, that means we have to shift some money from some treatment of current things—. And I'm not for a moment suggesting that that is about exposing people to risk of death, or anything like that—let's be very clear. But there is an issue about where do we put our efforts, and is it about managing people? We've chosen, with the Cabinet Secretary's support, a national diabetes programme, which we came in to talk to you about some months ago, because, actually, the burden of preventable death was too great for the system not doing things. But, in a way, that is an admission of the problem that we have, when we should be putting much more effort into prevention. In a way, you're kind of having to burn the candle at both ends, but you're burning the treatment candle with much more expensive tallow than you are burning the prevention one. And I'll shut up, because that analogy has just broken down.

I agree. I mean, certainly, when we talk to our public health director colleagues in the health boards, that is the issue they are grappling with, because the very small amount of resources they've got available to them, they have a choice to make between do they put them into treating the problem or do they spend it on helping to prevent the problem. Most of them, as you would expect, being public health professionals, want to spend it on preventing the problem.

But we also recognise that if you or somebody in your family was experiencing ill health as a result of severe obesity, you'd want them to get help. So, we've got to find a way of working through that particular challenge in the best way possible. We are not necessarily using the most cost-effective ways of dealing with this issue, there's no question about that in my mind. So, I think we can use the money that we're currently spending a bit better, and that's something that we're working on at the moment.

And this is not a short-term solution, but something that would help is if we really ramped up an ecology of patient self-activation and self-empowerment. I look at my mum, I look at the experience of others, I volunteer in a hospice, I've volunteered in HIV for 40 years, and one of the things those sectors get well is self-care and self-management and self-support. I think we're poor at that in the UK compared to most of Europe, and it's not a quick fix. But if you really got some of the work that's done by Diabetes UK, for example, and Stroke Association UK around self-care, you could make a big difference to hospital admissions. And we know we've done it in heart failure, by self-care in heart failure, reducing hospital admissions in other cases, so it can be done, but that's not a quick fix.

John, do you have any further questions, because Jenny wanted come in?

Yes, just quickly on children, really, because your evidence to us has stated that services are relatively less developed in Wales for children, and where there is capacity, uptake is not very good. And then later on, when children are older, they're presenting, which obviously is not a very good state of affairs. What needs to be done about that?

I think that's back to the stigma issue. Whatever we have tried to get parents to engage with support for healthy weight for children has not worked particularly well. The research that we've done behind that suggests there are two problems. One is sometimes parents actually don't always recognise the problem. We've lost the ability to know what a healthy weight actually looks like, and they tend to underestimate where their child is on that spectrum. But, obviously, even when they're sometimes given that information, they don't positively respond, and that's where the stigma bit kicks in, I think. So, we need to be thinking about that element particularly, so that people are actually willing to accept support. Because most parents know what the answer is, to be honest; we all know what the answer is, don't we? We all know what's healthy for us and what's not healthy for us. There's not always a need for expert professionals to come along and tell us that. I mean, there will be children at the most acute stage, absolutely, and that's one of the challenges of us not talking about the problem. We know, from the services that do exist, they are finding evidence of children with non-alcoholic fatty liver disease in childhood, and their parents are horrified when they're told that, because we still don't think about obesity as a serious health problem, and that's part of what we've got to tackle.

I'm okay, Chair.

Jenny, you wanted to come in on this point.

Yes. It's all down to political leadership on one level, because the Healthy Start scheme, Lynne Neagle was shocked that the Healthy Start vouchers had 40 per cent take-up when she looked at it, and it took a mandatory training course for all health visitors and midwives to drive it up to over 70 per cent, and it may well be higher than that now. But how is it possible that our health professionals have just taken their eye off the ball on what's important here? Do they do nothing unless they're told to?

I think, if I reflect on my career over the 30-odd years I've been doing this, what you could talk to people like our health visitors, community nurses and midwives about, and they could engage with, when I started my career, and what you can talk to them about now, there's no comparison. There is so little capacity for them to do anything other than what is perceived to be the most urgent—and there might be a debate about what the most urgent things are—that it is really difficult to get this wider preventative thinking into people's consciousness. And we are bombarding them sometimes with too many of those things as well. So, I think there is something about a clear understanding about where we would like the focus to be and how we make it happen, but that's a really good example for me of—. We talked about there being lots and lots of behaviours, or lots and lots of changes here that are going to make a difference, and that's an example of taking a specific thing, identifying something needed to be done, doing something about it, and showing that it made a difference.

Okay. Well, we know that breastfeeding makes a difference. So, in your—

That's a lot more difficult to solve.

Huh?

A lot more difficult to solve.

Well, except that if we had—. Busy midwives aren't going to have the time to sit with a new mum and help them successfully breastfeed, as they need a multidisciplinary team, and I'm ever surprised that we don't have breastfeeding support workers working underneath a qualified midwife who will give that time. Why aren't we training up people in the community as well to do it? Because the difficult problems always happen after 6 o'clock in the evening.

I'm sorry to ask just for a quick response.

So, how are we going to do this? This is a disaster. We're about to hit the brick wall, and yet we don't seem to be able to take the decisions that need to be taken. So, what can we expect from this review?

I'm so sorry to ask for a short answer on that. I know it's a complicated area.

The review of—?

Review of—?

The review of maternity weight management services.

I see. Sorry. Right. Well, that's less of a review and more about setting out the standards in the pathway that we've done for other population groups that don't currently exist for maternity, but that's about weight management; that's not about the breastfeeding bit.

Okay. But you recognise the link, don't you?

Yes, completely.

Okay. Sorry. Mabon ap Gwynfor.

If I can just build on a question that John Griffiths raised earlier with regard to provision and where that provision is, would you—? You're aware of the inverse care law. Would you say that that same rule would be relevant in terms of provision for needs related to obesity problems?

Yes. I mean, I think the inverse care law is very clearly at work, so you can see it in the factors that mitigate for obesity and overweight in terms of food supply in poor areas. You can see it in the factors that mitigate for people who have greater resources to maintain a healthier weight and better food choices. The higher your disposable income—. The higher you earn, the less proportion of your money goes on tax; the less proportion of your money goes on food, almost, and nutrition, and you will have better food. You can also see the inverse care law at work in treatment and care services, and the example about minority ethnic communities and the issues there. So, the entire system is almost designed in a way that privileges people who have got more resources. Now, I'm not saying that someone has sat down and deliberately done it that way, but certainly commercial actors want to make a profit. There's nothing wrong with that; there's nothing wrong with employing people; it builds well for the communities, but, at the end of the day, that generates significant inequalities. So, even in the choice of food supply in the food deserts, it's the inverse care law writ large.

So, when it comes to thinking about where the Government or the health service should put these scarce resources, or where we should target programmes to tackle obesity, would you say then that we need to focus on those areas that are at present under-represented, perhaps, and target more resources on those areas? Is that the kind of policy you'd look at?

Yes, I think, if you come back to the future generations of Wales Act, to give everybody a level playing field, you'd start with the people who are furthest from the level playing field and build resources. I remember, when I worked in a previous job, it felt like half of Public Health England lived in St Albans. I did something in Stevenage and Watford, and then got a whole load of letters about, 'Why haven't we got it in St Albans?', and I just sent back the income figures for St Albans. Now, I know St Albans has got really difficult problems, but this sometimes means you have to make choices. So, where would you start? You'd start with the areas where you're going to have the biggest impact, and you'd start with the areas that are furthest from where you want them to be, because they will have the biggest impact. It's also the most difficult.

Now, I get the feeling that you and a number of others may have read Marmot and others—bedtime reading. So, Marmot talks about proportionate universalism, so that fact that—. It goes back to a book written by Geoffrey Rose in the 1970s, Preventative Medicine. So, if all you do is do something for everybody, the best off, the better off, get better results. If you shift the worst off, you just bring them up to level of the better off—you know, don't improve. So, if you do more for the people who are the worst off and a little bit for everybody, you begin to move everybody. That's the theory, and there is some evidence it works, but you have to load, I think, in respect of the inverse care law. Sorry, that was too long, and I do apologise.

Thank you, Mabon. In your paper you mention that no country has tackled the rise in obesity in adults. So, there will be good examples around the world. Is there any particular country that you can point to where is a good example that you can evidence or tell us that we should look more into?

I think there are good examples where people have tackled childhood obesity well.

Where are they?

There are a couple in Europe. So, places like Amsterdam have done reasonably well. There are some examples in Finland. There are some projects that are run in parts of the United States, place like Massachusetts, New York, Texas, that have had some success in that space. So, there are parts of Australia—Victoria has had a bit of a successful programme there.

In terms of adults, I think what you can see is examples of policies that are making a difference. So, you can see work that's been done around food regulation, for example. Brazil is a leader on the food environment and ultra-processed foods, for example. Canada is doing important work in that space as well.

I think the other thing that's interesting from the international perspective isn't so much about where you fix the problem, but actually where we can see international comparisons that help us understand the problem better. So, you've only got to go across the Channel, which isn't very far away, to France, and see what is a much, much lower rate of obesity, and look at their food culture and a whole range of—. If we look at European cities, in terms of active travel or public transport—massively different environments. So, it gives us a clue about the sorts of conditions that create better outcomes.

Thank you.

Perhaps also, in terms of food supply in really poor areas, bits of Slovakia, bits of Hungary, bits of Poland are well worth looking at. Sorry, I didn't mean to interrupt you.

I'd love to have time to talk more about this. If there is any information or other work that you've done that you could provide around good examples around Europe and the rest of the world, I'd be grateful for that.

Okay.

Thank you. Thanks ever so much for your time and your paper in advance of the session this morning. Diolch yn fawr iawn. Thank you.

We'll take a six, seven minute break.