Health and Social Care Committee
Oral evidence: Childhood obesity, HC 882
Tuesday 1 May 2018
Ordered by the House of Commons to be published on Tuesday 1 May 2018.
Members present: Dr Sarah Wollaston (Chair); Luciana Berger; Dr Lisa Cameron; Rosie Cooper; Diana Johnson; Johnny Mercer; Andrew Selous; Derek Thomas; Martin Vickers; and Dr Paul Williams.
Questions 1 - 91
Witnesses
I: Kieron Boyle, Chief Executive, Guy’s and St Thomas’ Charity; Laura Flanagan, School Food Improvement Officer, Croydon Food Flagship Programme; Gill Heaton OBE, NHS CHAMP; Sarah Vince-Cain, NHS CHAMP; and Dr James Nobles, Research Fellow, Leeds Beckett University.
II: Jamie Oliver, Jamie Oliver Group; and Hugh Fearnley-Whittingstall.
III: Professor Jack Winkler, Emeritus Professor of Nutrition Policy, London Metropolitan University; Dr Laura Johnson, Senior Lecturer in Public Health Nutrition, University of Bristol; Martin O’Connell, Associate Director, Institute for Fiscal Studies; Professor Franco Sassi, Director, Centre for Health Economics and Policy Innovation; and Dr Peter Scarborough, Associate Professor and University Research Lecturer, Nuffield Department of Population Health, University of Oxford.
Written evidence from witnesses:
– Guy’s and St Thomas’ Charity
Witnesses: Kieron Boyle, Laura Flanagan, Gill Heaton, Sarah Vince-Cain and Dr James Nobles.
Q1 Chair: Good afternoon. Welcome to the Health and Social Care Committee and our first session looking at what the Government should do in the second chapter of their strategy to tackle childhood obesity. We are hoping to take a particular interest in how we narrow the gap, because every year health inequality has widened since the child measurement programme began, and to take a “What works?” approach. Could we start by all of you introducing yourselves to those who are following from outside the room, starting with Laura Flanagan?
Laura Flanagan: I am Laura Flanagan and I am here representing the London Borough of Croydon. I work for Croydon Council as the school food improvement lead.
Kieron Boyle: I am Kieron Boyle. I am the chief executive of Guy’s and St Thomas’ Charity. We are an independent place‑based charitable foundation working in inner-city London on complex urban health challenges.
Gill Heaton: My name is Gill Heaton. I am the deputy chief executive of Manchester University Hospitals Foundation Trust. I am here representing the NHS CHAMP programme that we run in Manchester.
Sarah Vince-Cain: I am Sarah Vince‑Cain. I am a dietitian and work for Manchester University NHS Foundation Trust. I am the clinical programme manager for NHS CHAMP.
Dr Nobles: My name is James Nobles. I am a research fellow at Leeds Beckett University. We have been commissioned by Public Health England to provide whole‑system approaches within local authorities. I also work for MoreLife, who are a public sector weight management provider.
Q2 Chair: Thank you. To start, I would like each of you—and, perhaps, Gill and Sarah, one of you could represent the organisation—to set out what you would like to see in the next chapter of the childhood obesity strategy, particularly what you think will work to narrow the health inequalities. Shall I start with Gill or Sarah?
Gill Heaton: The work we have done in Manchester has been multi‑agency; it is everybody’s business. The most important people in that are the parents, the children and the schools. We focus in a multi‑agency way across public and private sector to initiate a programme of weighing and measuring every child in every primary school in Manchester every year.
That is quite a significant amount of data. Annually, we take in around 46,000 measurements. Every single primary school in Manchester is included in that programme, which is round about 137. We now have four data points for each child across the city of Manchester.
We then established a digital programme called CHAMP—children’s health and monitoring programme—which digitally feeds back that data to children and to their parents every year. We have tried to be very inclusive in our approach and feel that is quite significant in being able to target any interventions that we need to make overall.
Q3 Chair: Do you then actively follow up or leave it for parents to get back to you if they want to have help and support?
Sarah Vince-Cain: As Gill has mentioned, we measure all children every year in Manchester. That is carried out by the school health service. Soon after the measurements, the CHAMP team contacts the parents, either by email, if they have already registered, or by letter; the school sends a text out as well, which is very useful. Then parents log on and see their child’s results and previous results as well, so they see a trajectory, which is very important. They can also add their own measurements at various intervals.
We have found that, although we are available to support parents, as are the school health service, parents will assume responsibility, are very knowledgeable about basic nutrition principles and can often see exactly what changes can be made. The feedback tends to motivate parents to make those changes. The University of Manchester has shown that through the research that it has undertaken.
Q4 Chair: For you, it is about having the extra data points.
Gill Heaton: The other complementary factor is that we know that parents—adults generally—do not recognise children being overweight. That is a really critical factor in involving parents in the assessment and weight management of their children, because if parents do not think their child is overweight, then they are not going to start doing anything to prevent that or to improve that situation. The fact that their child’s weight is known to them, that it is known within the normal parameters and is confidential to them, enables those parents to make an objective assessment of their child’s weight as opposed to, “Well, they are the same as every other child in the class and therefore they are okay,” when 40% of the children in the class are overweight.
Q5 Chair: I do not want to go into too much detail at this stage because we are probably going to return to these points in a minute, particularly about the inequality aspects. At this point, James, could you give us an overview of what you think is absolutely essential?
Dr Nobles: When I looked back at the childhood obesity plan earlier, the one thing that really struck me was the lack of additional Departments involved in this strategy. When we look at the systems that drive obesity—such as the Foresight report, which has over 100 factors that drive obesity—the Department of Health and Social Care is not the primary one creating the current environment. We have to draw on these wider Departments, the wider sectors, to pull on their expertise and on their enthusiasm. They have so many levers available to them. If we can draw on those levers, we can create more of a governmental-level, whole‑system approach to tackling obesity.
At the minute, when you look at the childhood obesity plan, 14 points are on there, which are very much driven in individual silos; they are working towards their own individual goals. There are no collective goals that that childhood obesity plan is really working towards, and it definitely is not bringing in the wider sectors to do so. There is evidence from elsewhere, which hopefully I can talk about later, that does bring in those wider sectors.
Q6 Chair: It is about having the whole‑system approach if we are going to address the inequality aspects.
Dr Nobles: Absolutely.
Kieron Boyle: In south London, we are trying to take one of these whole‑system approaches to tackling childhood obesity, and I welcome the Committee’s focus on narrowing this deprivation gap. It is important for us to speak with sufficient candour about this. Kids from poorer backgrounds are more than twice as likely to be obese, and that gap has grown by over 50% over the last decade. I find that really helpful to ground the really practical realities.
Talking about two places a couple of miles down the road from where we sit right now, Dulwich Green has an average household income of £60,000, one in five residents of ethnic minority backgrounds, and one in 10 kids are obese. Compare it with Camberwell Green, just up the road from Dulwich, where average household incomes are £30,000, three in five residents are of minority ethnic backgrounds, and one in three children are obese. Indeed, it is one of the first places in the country where a minority of kids have a healthy weight.
So, we need to focus on the environments in which children are living, which is certainly what our work is trying to focus on. How do you intervene in the home, in schools and in the street to create environments that make the healthy thing to do the easy thing to do?
Q7 Chair: For you, it is about making the healthy thing the easiest thing to do in tackling obesity; that would be your focus.
Kieron Boyle: Yes, absolutely.
Laura Flanagan: Broadly, I would like to see more of an emphasis on physical activity. Going forward, out of the 14 actions, two are around physical activity and the remainder are around food. We are aware that food has a huge impact on healthy weight—absolutely—but it would be good if we could push and raise the profile of the risk of sedentary behaviour, and not just sporty, physical activity in schools, for example.
In schools specifically, we absolutely need to have a continued focus on school food standards and raising the quality of food in schools. Absolutely, school food has transformed over the last 10 or 20 years, but there is still a really long way to go. Where the focus has been on school meals, particularly at lunchtime, we have lost the other parts of the school day. I see poor food, in reality, in breakfast clubs, at break time, in tuck shops and after-school clubs. It is about having a consistent, whole‑school approach and schools recognising that food is important across the school day—and, going forward, that being reflected in some of the guidance and support around school food standards.
Chair: Thank you very much for that overview. Andrew is going to ask questions.
Q8 Andrew Selous: Could you talk to us about the good practice that you have identified locally and how we can best spread that out around the country? We have obviously had a plea to have a cross‑Government approach, which many of us very much agree with, but given the scale of the problem, how do we move these good examples of practice in Manchester, Camberwell, Croydon, and so on, and make sure that they happen country‑wide to deal with the scale of the problem?
Gill Heaton: At the outset, in Manchester, we wanted our approach to be mainstream across all schools across Manchester, Greater Manchester, the UK and internationally. There is no restriction on our programme. It is cost neutral. We did not have a huge amount of investment to set up the weighing and measuring programme, and we built on existing services.
Q9 Andrew Selous: When you say it is cost neutral, talk me through exactly how that works.
Gill Heaton: We already participate, as every other place does, in the national child weighing and measuring programme. We in Manchester felt that to weigh a child in reception class, and again in year 6, and to find that a lot of them had grown beyond what you would expect, was no surprise, really. What we could not understand was whether there were any points in that child’s life, in that four to 11‑year‑old time span, when their weight particularly increased. There were no measurements of that child between the beginning and the end point.
We took the view that we needed to measure each child every year against themselves, so that we would be able to see if there was any comparison between ages, ethnicity, gender, deprivation, or geography—whatever the parameters might be. That is why we have now been doing this for four years. The University of Manchester has been evaluating that for us, so there is an evidence base to support it. We did not want to generate a lot of cost in doing that, because then people say, “Oh, well, they do it in Manchester because they’ve got all this money and we can’t do it anywhere else because we don’t have the money. Therefore, there’s no point in us trying.”
We changed the technology in the way that we weigh and measure our children—purely and simply with scales and wireless technology. I am already out of my depth, so Sarah can give you more detail on that. But it means that our school nurses, who already go into all 137 primary schools in Manchester, across the city, can weigh a whole school in the same time that they weighed and measured two classes before. That is why it is cost neutral: it is no more time and no more effort.
Q10 Andrew Selous: Excellent; thank you very much. Kieron?
Kieron Boyle: I will put in a plug for a report that we have written almost precisely on this question. As we have looked at the evidence internationally, this is primarily a co‑ordination problem—that is, the evidence is known on what is successful in tackling childhood obesity. The difficulty is getting it all done at the same time and in an affordable fashion. Of course, there are some things that can only be done nationally, and other people today will speak to those, but it is important to focus on the local context, as you are.
We see, there, that the actual intervention itself might not translate from place to place, because you need to be specific to the context in which you work. For example, there is probably going to be a different answer as to what works for the Portuguese communities of Lambeth compared with the white British communities in Newcastle, but the process of drawing from international evidence and then co‑producing that with communities can be consistent across the piece. That might be one area where greater attention is given to how we unlock the capacity of communities themselves—specific potential.
Q11 Andrew Selous: Can I quiz you further on that point? We are probably all signed up to multi‑agency and that this is everyone’s problem, but how do you get proper local leadership, someone having a grip of the problem overall, bringing everyone to the table and saying, “We are going to do this together”? What are the levers? Is it the local authority as leader; is it the leadership of the health service locally, or education leaders, or all of the above? Is one person in overall charge?
Kieron Boyle: There are lots of different models of this. It is probably all of the above. The interesting thing that we have seen in our work is essentially what the anchor organisation is that can sit behind the co‑ordinating activity. The questions we ask in our work are essentially: where is there energy to do something, and where do the assets sit that can support that energy?
To give a practical example, it might be faith groups in a particular area. When we work in south London, faith groups are a really important part of civic life there, so that is where we might be focusing effort. I do not think there is one answer to that, but there is a consistent process behind what an anchor organisation that can support that process looks like.
Q12 Andrew Selous: I guess, if we are going to spread this across the country, we are going to have to think about models that we can pick up from what you have done in south London and move around the country.
Chair: Sarah and James both want to come in.
Sarah Vince-Cain: As to a whole‑system approach, we feel that parents are the key. If you directly engage with parents, then you are directly engaging with the whole system. People’s parents are teachers, researchers, chefs and software engineers, so you engage with the parents. If you motivate the parents, you are motivating the whole system.
We drew a group of multi‑agency organisations together when we started on our journey about three years ago. Gill was very keen to be entirely democratic, but we found that all our partners were looking squarely towards Gill as an NHS representative, recognising that people trust the NHS to give value‑driven information. So absolutely, we all have a part to play, but it has been very clear that having the NHS lead on this programme in Manchester has been invaluable.
Q13 Andrew Selous: With the more disadvantaged groups, which the Chair quite rightly drew our attention to at the start, are you making the right amount of progress with those groups in particular?
Sarah Vince-Cain: Absolutely. My first point would be to say that there are ethnic groups who start primary school with a low incidence of overweight and obesity but finish primary school in year 6 with an exceptionally high rate. Therefore, we have to monitor and help parents monitor their child’s growth through these years, otherwise we are going to be feeding back to parents to say, “Your child is fine,” and they are going to think they are fine for the next six years or so. We have to measure annually, but the feedback is vital.
We have schools that have a great take‑up of the digital system. Eighty per cent of parents signed up in a flash to see how their children are growing, but a parent’s interest in their child’s growth is universal. There is no better motivation for parents who maybe do not have email addresses to get signed up and get connected. We have schools out there that help them. More than half our primary schools in Manchester are in the lower decile for IMD, but that does not put our school leadership teams off pulling them in, getting the wi-fi, getting the iPads in, and getting these parents connected, improving computer literacy and health literacy as well.
Dr Nobles: We have been commissioned to do work through Public Health England to generate a manual and a set of resources that would enable local authorities to work towards a whole‑system approach to obesity. We have sculpted a six‑phase process that we have now worked through with 11 local authorities. We have feedback from that and are testing it out, but as to how we make these things move forward or how we get those different sectors involved, we have found through the feedback that we have received that we need to understand the priorities of the different sectors to see where obesity and the themes around health fit in with what they are already doing, as opposed to just sometimes expecting other sectors to want to get involved in what we are doing.
We have had to learn about the priorities of the different sectors—what transport and planning are trying to do—and to tie in the obesity‑related work with that, and draw on the levers available in those wider sectors.
Another element that we have to work on is keeping something such as obesity as a burning-platform issue. Local authorities have so many different priorities that they want to work on at all times. A whole‑system approach is a way of working; it is a way of seeing the whole system. It is not just about obesity, but seeing that we have all these different agendas across the local authority, and how we bring those together in a way of working that is a whole‑system approach. It is about understanding those different agendas and bringing them all together. The route map and the process that we have created for local authorities is a mechanism of doing that. We just need to get the leadership in the room, around the table, to open up the doors to bring other members in as well.
Q14 Andrew Selous: Finally from me, before handing over to other members, how would you summarise your views on the progress of the Government’s childhood obesity plan to date, starting with James?
Dr Nobles: The childhood obesity plan is a really good first step. It shows that there is some movement there—that we want to take this forward. It is not collective; it is not bringing all the points together, and it definitely isn’t looking at the one in three children who have a weight‑related issue right now. It is very much from a prevention focus. It has things such as the soft drinks industry levy in there, so that is a higher level of action, but there is nothing there to support children who have a weight issue right now. For me, that is one of the big bits that is missing. There is nothing there aligning with what Sarah has been saying. You have the NCMP but then nothing to refer children on to, which are weight management services.
Q15 Andrew Selous: How can you call it a good first step if the graph is going the wrong way at the moment?
Dr Nobles: It shows that there is interest in this. We have a childhood obesity plan written. I did not say it was a good childhood obesity plan. There is that traction there.
Q16 Andrew Selous: Does anyone else want to comment on the Government’s plans so far?
Gill Heaton: I do not feel in a position to comment on the Government’s plans, but my perception of it is that it is not ambitious enough. We have a ticking clock. At the moment we know we have over 2,500 children who are severely overweight or obese in Manchester. That is the equivalent of six or seven primary schools. Those children are unseen to the services at the moment because they are not unwell, but they will become unwell, and we know that and can predict that.
Q17 Andrew Selous: So there is a lack of urgency.
Gill Heaton: It is not proactive enough for us and, to a degree, it is not prescriptive enough.
Kieron Boyle: I can see three areas where it could go further on. One is that it is oddly light on the role of communities in this. I think we miss a trick if we do not unlock that civic action.
Secondly, it is right to focus on the role that the state can play. I will give one practical example. In our ethnographic work, we have spoken to the owners of fast‑food shops. They do not want to be selling unhealthy food to people, but they need to work out what is a commercially sustainable way of selling healthier food. We need to get into that sort of territory.
Thirdly, we need a road map. Everybody recognises that this is a complex issue. To have a genuine 10‑year plan, we need to say what we hope to see after years 1, 3 and 5. Year 1 need not be that ambitious if we know that it is pointing toward where we need to be by year 10. Those are the three areas where it could go further.
Laura Flanagan: I agree with lots of the things that have already been said. I think the plan, at a very local level, was exciting when we got it, because it felt as if it was creating a momentum and was a platform for us as a local authority to start saying to schools, settings and businesses, “Look at what we have. This is what we need to do moving forward.” Unfortunately for us, we have found it challenging when some of the actions, where there were dates when things would happen, have not happened. That has a negative effect at a local level because we are then seeing that people become more disinterested and negative towards the plan itself. We would like to see a continuation of some of those things, such as the school food standards, being reviewed; a health and rating scheme for schools; to have specific dates in there that have not yet been actioned to be taken forward.
Chair: Thank you. Johnny and Lisa want to ask quick supplementaries, and then we are coming to Luciana.
Q18 Johnny Mercer: I am interested to know this. Clearly, we all understand the fight against obesity, but the drama in places such as Plymouth with fast‑food restaurants, and so on, is this accusation of the nanny state. How do you counter that? In your experience, in what you have worked in, what are the arguments in the other direction, James?
Dr Nobles: If we look at the environments that we have, I do not think we have necessarily chosen to live in these unhealthy environments that we have right now. That is where I would start. We are responding to the environments that we have around us. We are just undertaking normal behaviours in the environments we are in right now. People are not choosing to be obese. People are not choosing to increase their weight. That, for me, is the key to this. We believe that people are choosing all of these options. We know that the majority of decisions people make on a day‑to‑day basis will be made out of habit; they will be made automatically. For us, understanding the way in which human behaviour works, we are not always making conscious, rational decisions at every step. There are a number of points that we could take forward on that.
Q19 Johnny Mercer: Does anybody else have a comment?
Laura Flanagan: We have been doing lots of work in Croydon, but we had a big push around this when we became a Food Flagship borough. One thing we did was to focus on food rather than healthy weight, which we found was a real positive because everybody is interested in food. We also took a very positive approach with the programme, so that we were educating residents and businesses, and offering opportunities. We were offering training and schemes. We kept the focus very much on supporting them by giving them information, and then they could make their own choices, rather than, as you say, having that nanny‑state response. That really helped with the programme.
Gill Heaton: It is about not doing it to people, because none of us likes having it done to us; we like people to do it with us. It is about making sure that people have informed choices, and empowering parents and children to make those choices.
Kieron Boyle: This is an important question. We should recognise how endemic the framing of this is. If you ask a person on the street what causes childhood obesity, they will say that it is normally down to insufficient willpower. James has made a point that a lot of it is to do with the environments in which we live. We have asked the questions of people who live in the most obesogenic environments in the country what they think causes childhood obesity, and their answer again is that it is about insufficient willpower—about people making bad choices. So, even people with lived experience of environments where it is really difficult to make a good choice do not have a free choice quite in the way that we suggest. We need to be clear about how endemic that is.
Sarah Vince-Cain: I would say, first, that the data is imperative. We are able to feed back data at different levels in Manchester now. That has a big impact. It has an impact on the family and on the school. School leadership will say, “My goodness, I never knew that that was the profile in our school. I am going to stop that ice cream van from parking outside the gates”—that kind of change. Then we can feed back to local groups and say, “Look, this is the situation in your ward.”
Everyone thinks it is somebody else’s problem, but as soon as you highlight the problem right there, right now, everyone has the right answers. Then they can forge those solutions themselves. I am so tempted to give solutions all day long, but you cannot do that because it is not the right thing to do. People know what the answers are inherently and they will make those choices.
Johnny Mercer: At the weekend, even my four‑year‑old told me that I had to eat less.
Chair: We have all been thinking it, Johnny. Lisa, over to you.
Q20 Dr Cameron: I have a quick question about how you get the focus right for young people so that they do not feel labelled and stigmatised in terms of their weight level at a young age and it affects their self‑esteem. Also, are you able to pick up children at the other end of the spectrum as to whom there may be warning signs of anorexia, for instance, or undernourishment?
Sarah Vince-Cain: You are absolutely right. The language is key. We have to use the right language; it has to be kind language and it has to be useful language. It should not get stronger and it should not get aggressive.
In terms of communicating to young people, we communicate to parents, and the key is to normalise measuring children, celebrating the growth of children and for children to be interested in their own growth. We have just done a consultation with young people as well. How do we transition this information from parents to young people? Are young people interested? They definitely are interested. Young people will help us determine the kind of language that they want to hear.
Also, you are absolutely right in terms of trajectories. A child’s growth pattern is a fundamental indicator of health and wellbeing. Our work enables us to see a child’s growth trajectory taking a steep downward or upward trajectory, and that can raise alarm bells. Our GPs across Manchester can absolutely see the value in them having this information. Our GPs are telling us that, often, they do not see children for years on end until the parents come along to the surgery and say, “My child is losing weight; I am sure she is losing weight.” The GP would not know. To have access to this trajectory would surely make their lives a lot easier and affect clinical decision making.
Q21 Dr Cameron: So there is a way of moving that data on to help children who are critical.
Sarah Vince-Cain: Yes, completely.
Q22 Luciana Berger: In different ways you have all advocated that whole‑system approach, and you have been very positive about what you are doing at a local level, which is exciting for us to hear, but can you share with the Committee what you think the barriers are that you would like to see the Government address in the next phase of their obesity plan and how you would like to see those barriers removed, if at all?
Further to that, what specific further support or powers do you think local authorities should have to further address issues to do with obesity? Who would like to start?
Sarah Vince-Cain: I will start. Local authorities have a huge part to play. That link with health is imperative. Of course, I think that the digital growth chart is key from birth. The local authority can play into this maybe at birth registration, at school admission, primary and secondary school. There are lots of key points where we can come together and promote this.
I also think that research has to play a huge role. The University of Manchester has sat alongside us at every step of the way. That has been invaluable, not only to evaluate and analyse our work, but to give different insight into how we are approaching this.
Dr Nobles: One thing to add is that local authorities really do want to address this. Among the 11 local authorities we have worked with, there is a real appetite to be able to work on this. As I mentioned earlier, it is not necessarily always a burning‑platform issue, so how we can give them support to keep this a burning‑platform issue is paramount.
The next bit is that there are really good examples of the ways in which local authorities have worked on issues around inequality and issues to do with the wider determinants of health. There was a really good report published by the Health Foundation, which gave some tangible examples of how local authorities have worked on the wider determinants of health. They need to be able to learn from each other and to learn this best practice. Government and maybe the Local Government Association could really work on how local authorities can best share learning across and between each other.
Q23 Luciana Berger: In spite of those 11 pilots going on at the moment, we know, as my colleague pointed out previously, that the inequalities are widening and this problem is getting worse. To the side of what your pilots might be doing, what is going wrong? What barriers need to be broken down?
Dr Nobles: You need to consider maybe the approach that we have taken to date, especially if you look at local authorities who do incredibly good work. A lot of intervention is delivered, though, at a very individual level in providing support through physical activity sessions and weight management sessions. The challenge that we have is that, with those services, we do not necessarily tend to get the engagement from those with whom we always want to work. It is more difficult to work with those from more deprived backgrounds. It is for us to work out how we can modify our approaches to work with those who are from the most deprived backgrounds. There are very good examples of that working, but it is about how we do it more broadly and in the context of local areas.
Gill Heaton: There is absolutely no shortage of people involved in this area of work. The big thing that struck me four or five years ago when I began to get involved is just how disconnected it all is. There is lots of enthusiasm and energy, but not a lot of impact and effect, if we are being absolutely honest.
I think there is something about an overall approach—a national coverage. If you think about screening programmes, immunisation programmes, things where we really want to target an intervention or prevention nationwide, we have a strategy that everybody adopts. It might not fit precisely—one size does not fit all—but there is something about having something that works in Plymouth that also works in Newcastle, and that when children move around the system they do not get lost to it. At the moment it is highly benign, very optional, voluntary and negotiable. If I don’t want to do it, well—do you know what?—I don’t really have to.
Without going into the nanny‑state argument, there is something about having a level of consistency and continuity, and a little bit of prescriptiveness, so that we are not doing the things that we know are not of any benefit but are channelling our energies into where they are. I know I am a bit fixated about it, but I think that weighing and measuring is the absolute starting point for a stocktake of knowing where we need to make our interventions.
Andrew Selous: Absolutely.
Kieron Boyle: A simple but tricky point is timeframe. It is fantastic that Sarah and Gill’s initiative has been going for more than four years on this, and certainly when we did our research we found lots of examples of initiatives that lasted two or three years. The difficulty around something such as childhood obesity, which we know is a systems problem, is that systems are adaptive, so you do one thing over here and it interacts sometimes in unpredictable ways over there. If we are only taking a two- to-three‑year look at this every time, it does not really have any ability to respond to that.
Laura Flanagan: Representing a local authority, the barriers for us are that we have many different things to manage and put our resources into—absolutely. We are trying to spread the theme of healthy weight across different departments within the council. Historically, it has maybe been a public health problem, but we are not going to solve it that way. With the Food Flagship programme, initial funding certainly helped us, absolutely, because we could invest resource and we could recruit, because we needed people in this dedicated role.
Apologies—I have just lost my next point, but if it comes back to me I will come back to you.
Chair: Did you want to come in as well, Diana?
Q24 Diana Johnson: I want a point of information. James talked about the 11 areas that you have been piloting. Could you say where the 11 are, because I could not find them in the papers?
Dr Nobles: We are working with 11 local authorities. We are working with Durham, Lewisham—this is going to be quite a difficult list to go through—Hertfordshire, Oldham, Bradford, Dudley, and who else do we have? Gloucestershire and Lewisham, if I have not already mentioned them.
Diana Johnson: You can send us a list.
Dr Nobles: We will be able to get that for you.
Q25 Chair: Can I follow up on one point? You mentioned that there were some interventions at individual level that you thought were working but you did not elaborate on the ones that are most effective, particularly with that focus of narrowing inequalities, that kind of “What works?” approach.
Dr Nobles: Looking at the childhood obesity plan, the one thing that is not in there is how we can help those who already have a weight‑related issue. Weight management services are effective if we are able to have the sustained impact afterwards, which kind of comes into the environmental factors around it.
In the work that we have done through MoreLife—and we have evaluated the data going back quite a long way—we find that about 70% of the people are living within the most deprived areas, so we can deliver those interventions in areas of greater deprivation, but at the moment there is very little funding to be able to deliver those services. It is not a mandated responsibility for local authorities or clinical commissioning groups to have weight management services in place. It falls into the non‑statutory services.
Sarah Vince-Cain: I have a small point I would like to make. Gill alluded to the fact that 6% of our children in Manchester are severely obese—6%, so 6,000 just in the city of Manchester from nought to 18. The emotional consequences of being overweight often manifest themselves ahead of the physical consequences. It is really important that we pick these children up, but it is likely that they and their families will need a whole range of multiskilled professionals supporting them over a long period of time.
We work closely with the Manchester and Salford eating disorders service. We see lots of parallels between children at both ends of the scale—children who are very light and very heavy. It is a similar system that probably needs replicating and scaling up to support these children.
Q26 Chair: Before we move off what are the levers that are missing, in our last inquiry we touched on things such as whether, within the planning system, you had sufficient levers to be able to do the things that you wanted to do. Kieron, do you feel there are things missing from the powers that you would like to be able to deploy?
Kieron Boyle: That is very interesting. I do not know the exact answer to that specifically around planning, but when we are designing to the built environment, it is absolutely critical that we are designing it with active movement in mind. I do not know specifically on planning regulations whether they allow enough of that.
Q27 Luciana Berger: Added to that, are there any powers that you think could make a difference in local areas around not just planning but licensing of the location of fast‑food outlets; curbing advertisements and billboards for various foods that are high in fat, sugar and salt; and also sponsorship in those local areas?
Laura Flanagan: All those things really, because they are the things that are beyond our control at a local authority level. We are hearing from residents and schools that they are engaged in lots of things and they want to make changes, but then they are faced with unhealthy high streets, unhealthy check‑outs and promotions on lots of high‑sugar, high‑fat foods. That is very challenging for them, and it is hard for us to address that at a local level. Specifically around planning, licensing around existing food businesses is the challenge for us and their proximity to schools.
Dr Nobles: We found within the local authorities that they have a range of things within their control, but they really want to see national Government taking leadership on the bits outside their control. We quite often hear stories of helplessness or, “Why should we bother if national Government are not bothering?” They really do need to see more from national Government to show that national Government are there supporting them so that they, as a local authority, can work in the areas in which they also have leverage.
Q28 Chair: What are the areas specifically where local authorities most want to see those big levers available?
Dr Nobles: I think it is what has just been referred to. It is around the advertising. The media is a huge one. It is what has already been covered, but the media is a big one that has come back to us as well.
Q29 Andrew Selous: Camberwell Green, which is in your area, Kieron, was featured in The Daily Telegraph last week. You have four primary schools, and, from memory from the article, there are something like 40 different fast‑food takeaways. The article went into some detail about what you could buy for a pound, which was incredibly unhealthy, and these were special schoolchildren offers. Some local authorities—Gateshead, I believe—are already taking action and are stopping these unhealthy fast‑food outlets from proliferating near schools. I am surprised that you are not all stronger on this. It seems to be something that we should very actively be taking an interest in.
Kieron Boyle: It is a very important area to take an interest in. To build on that, when we have looked at why children go to fast‑food stores, the answers we get back are quite interesting because the food being served is low down the list. They are places where kids feel safe, they are warm and they have free wi-fi. So, it is about getting an understanding as to the environment and why kids are going to these. Yes, absolutely, look at the planning side of it because it is very important, but we need to understand some of the user journey against all that.
Q30 Dr Williams: My questions are about early years because we know that particularly the first thousand days of life are where many of the seeds of inequalities, including inequalities around weight, are sown. We also know that more than 50,000 children begin school obese. I have just spent the weekend looking after my two children while their mum was away—a three‑year‑old and a five‑year‑old—and I am sure you will share my pain that the three‑year‑old knows and recognises the logo for McDonald’s, although she says it is grandma who takes her there, but also the joy that my five‑year‑old joined me in duathlon training and was really active as well.
I am keen to know from you, because inequality starts early, what you think about how the recommendations that the Government have made around early years are being implemented and what more needs to be done in the early years. Maybe you could start, James.
Dr Nobles: Can I pass this on? It is not one of my areas of expertise.
Laura Flanagan: I will start. It is not my role. Although it is primarily schools, it is also early-years settings, because we recognise in Croydon, exactly as you are saying, that we need to start with the youngest children and that saves us time and money later on; so, absolutely.
There are two key actions in the plan already around early years—a Healthy Start—and the uptake of those could be better. Nationally, it is 60% to 70% of those families eligible for Healthy Start vouchers. So, we really need to work on that and we are certainly doing that in Croydon.
The updated menus and guidance for early-years settings is key. We have so many children attending different early-years settings and we must get the food right in those settings. The guidance is excellent. I have to say that I think it is fantastic, and, when I have shared it with settings, they think it is brilliant; it is helpful and practical, but it is voluntary. Most settings are not aware of it, and if they are not aware of it they are basing their menus and food choices on their own knowledge and experience, and we need to get that message out there. In future, I think we need to raise the profile of that resource because it is already there.
One quick thing would be something like the Healthy Early Years programme. The Healthy Early Years London programme has just been piloted and we were part of that in Croydon. That platform, which is now rolling out, is perfect for early-years settings—and when I say “settings” I also mean childminders—to become Healthy Early Years accredited. Food is an essential part of that, and it would really support them to work through that and improve their offer for children.
Gill Heaton: When we started on our work programme around reducing childhood obesity, one incentive for us was that we were a whole system in ourselves in that we employed the whole of the workforce right from conception, with the midwives, right through to the health visitors, school nurses and so on, so that we felt we had touchpoints at every point along the child’s journey that could help with information, assessment, evaluation, and so on. We also employ all the community teams so that we have a reach into all aspects of child health across the city. Sarah, by background, is a paediatric dietitian and has done work within homes, so she may want to add to that.
Sarah Vince-Cain: Yes. The CHAMP programme, I guess, is bound by the NCMP, so it is an extended NCMP, if you like, but of course it was always our ambition to work backwards to the early years. Our research from the University of Manchester has shown that, if we take measurements between the ages of three and six, that will enable us to predict potentially how a child’s growth is going to pan out over time. We always knew that we had to head back into early years.
We are undertaking a nursery pilot at the moment, so we are now going to be offering parents feedback on their child’s growth from nursery years. Half of our children in Manchester attend primary schools in the nursery year. There are lots of other locations as well, which presents a different challenge.
We also created a system whereby health visitors at the two‑year check will be able to input the measurement on to the digital growth chart, so we will be able to see that growth pattern and get parents connected from a much earlier age of the child.
Q31 Dr Williams: I am very glad you mentioned health visitors, midwives and people who are providing support in the early years, but it cannot be any coincidence that we see inequalities widening at a time when there are fewer health visitors, fewer Sure Starts and fewer family centre environments, and certainly people tell me that breastfeeding support services are being cut as well. Is it also your experience that the very services that might help at the beginning of life are being withdrawn because of the austerity programme that we have endured for the last five, six or seven years?
Gill Heaton: I can only speak for my foundation trust, and that has not been our experience. If anything, we have expanded with the health visitor programme that was initiated five years ago. Sometimes it is about reviewing the priorities of the staff whom we employ rather than doing more of the same. If the priorities within the area in which we live and work determine a different way of working, and we can use technology to speed up certain aspects of the care and work, such as we have done with school nurses, we can benefit from that and see more clients, more patients.
Q32 Dr Williams: What is the experience in London?
Kieron Boyle: I cannot really talk to that except that this stuff does take people, doesn’t it?
Q33 Dr Williams: Is there anything else that you feel that the Government’s update to the childhood obesity plan should be doing around early years that it is not currently doing?
Sarah Vince-Cain: I am sorry that this might be a little bit too much detail, but the NHS number really needs to be a unique identifier for children, because it is very difficult. Take, for example, the school setting, where children might be registered with one name in the school and with another for health. If we are undertaking health work in the school setting, we have to be very clear that we are getting the right child. Having a unique identifier across the system—and it has to be their NHS number, I would imagine—should be tied into this.
Another small detail within early years is that when we are measuring children there are two datasets running alongside each other. We have the World Health Organisation two-to-five charts, and we have the UK 1990 dataset. We need clarity on this point. When we do schools, it is not such a problem. If we are looking at early years, it is not such a problem, but it is not just about these two groups. When they overlap, there is a point at which there is an inconsistency and it is not workable, so clarity on that point would be useful.
Chair: Thank you. I am conscious of the time, because we are already running into the time for our next panel, so, Diana, do you have any follow‑up points before we finish with Derek’s questions?
Q34 Diana Johnson: About schools, yes. I wanted to ask particularly around what Laura said about the improvements in school food over the years, which I think is right, but at either end—breakfast clubs and perhaps after‑school clubs—the food or the snacks being provided are not healthy. Also, could you comment on whether, with the new structures in education, with so many schools now being academies, you feel that the advantages that have taken place over the years are slipping back? Also, what about packed lunches, which relates to parents and their understanding of what is good to feed children at lunchtime? Could you put all that together and say what we need to do?
Laura Flanagan: Yes, absolutely, and I will try to be concise. I touched on school food. I support schools with food across the whole school day, and, absolutely, I have seen some really poor food being served in breakfasts. That is not because the staff do not care for the children or do not want to do the very best job; they are very unaware about what is appropriate and they want those children to be happy in that setting.
We need to do more so that schools and settings understand what food is appropriate for children in school. The guidance is there, but it is about getting it out wider with the school food standards. We run training programmes; we work on a local level; so, it is a little bit easier, and we have direct contact with schools.
With regard to academies, in Croydon, we have not found a different approach between maintained schools and academies. It is not the fact that the standards are mandatory for the maintained schools and not for some academies. It is more about the will, the personal beliefs and desire within the school, and it has been for us very much about educating staff and sharing data, we have heard, with headteachers so that they understand why this food should be better in their school.
The final one on is packed lunches. I would be here for a very long time if I started talking about them. It is a tricky one. We are doing a lot of work, and again we are supporting schools with resources, training programmes and toolkits, so that they can work with parents and educate them so that it is not a school telling parents what they should have in a packed lunch. It is very much about the approach, and we have to get that approach right if we want people to buy into this—but it is absolutely possible.
Diana Johnson: Can I say one other thing very quickly? Obviously, we are discussing obesity, public health and all of that. There is very clearly now evidence around educational attainment linked with good nutrition, and to get buy‑in from schools where that is perhaps not happening at the moment we could make it clear that results can improve. For example, in Hull in 2004 to 2007 we had an “Eat Well Do Well” scheme, which was all about increasing educational attainment as well as making sure children were eating healthily in school. It is quite important to get that message across.
Q35 Chair: Would you agree, James, that there is evidence to support that?
Dr Nobles: Absolutely. The one key bit that maybe was omitted there was that, also, physical activity for children in schools can have key benefits on their educational attainments. It is how we show schools the benefits of being physically active, having a really good diet, managing weight across the school, and also making the school into a very safe environment for people who may be of different weights as well.
Chair: We really do have to move the questions on. Derek, can we have your question next?
Q36 Derek Thomas: You have already made the point that the strategy does not strike a balance between prevention and treatment. This is not necessarily all the panel, but what do we need to do more in the strategy to help and support those who are already overweight?
Dr Nobles: You have a really good resource in the NCMP. You have the data there that can be used, if it is used properly and adequately, to refer people into weight management services. When you look at the funding in weight management and the premise of weight management services across local authorities, less than half of local authorities have weight management services. That is not taking into consideration the scale at which they are being delivered. Look at the diabetes prevention programme for adults; that is a well-resourced service for adults. There is nothing there like that for young people.
We can develop very effective weight management services, but they need, as Sarah was saying earlier, very well, highly trained staff, and also to be able to cater for the emotional and psychological needs, not just to be able to treat people and tell them what they should be eating and being more physically active. We know what those services look like. It just requires quite a lot of resource to be able to deliver them as intended.
Q37 Chair: Perhaps you could send us some examples of where you have seen that working most effectively. That would be helpful.
Dr Nobles: Yes, absolutely.
Gill Heaton: Briefly, we have the Royal Manchester Children’s Hospital within our group of hospitals, and one of the most worrying things we are seeing now is what we call tertiary referrals, which are referrals from other hospital paediatricians into our children’s hospital for children between the ages of two and 10 who are presenting with diseases of adult life—hypertension, heart disease, type 2 diabetes, fatty livers, and so on.
The children’s services are not equipped to deal with that multidisciplinary approach, because it also affects children’s mental health, their educational attainment, their emotional wellbeing, harassment, bullying and school refusal—all those things. It requires that multidisciplinary approach. This is a new problem that is now emerging in terms of the very sharp end of the heaviest children who are struggling to be able to be managed in the community.
Chair: Thank you all for coming this afternoon; it has been very helpful.
Examination of witnesses
Witnesses: Jamie Oliver and Hugh Fearnley-Whittingstall.
Q38 Chair: We have the props back. That’s great.
Jamie Oliver: You know we like a prop, Sarah.
Q39 Chair: That is great. Welcome back to the Health and Social Care Committee, Jamie, and thank you as well, Hugh, for coming this afternoon. As I explained at the start of the last panel, we are particularly interested to hear views on how we narrow the widening gap in health inequalities around childhood obesity and to take a “What works?” approach. We are really interested in both of your perspectives on that. Perhaps, in opening, you could tell us what you really want to see in chapter 2 of the childhood obesity strategy and why it will work.
Jamie Oliver: From my point of view, I have been tracking and working in this area since the school dinners campaign 14 years ago. Now is the time to start not looking at single approaches but at a multi‑pronged environmental approach, where there are really strong pillars, where every single Minister in every single Department in Government has a role to play, and that it is clear, aspirational and measured.
The crisis since the millennium has only got a lot worse, and to say it is a catastrophe or an emergency is fair and true. If you speak to anyone in the NHS—doctors, paediatricians or dentists—this is a massive problem. If you asked Mark Carney at the Bank of England whether British kids and adults being unhealthy and less productive is good or bad for the economy, he would say it is bad. I am looking forward to a chapter 2 that is environmental and broad.
Q40 Chair: Thank you. How about yourself, Hugh?
Hugh Fearnley-Whittingstall: Jamie is absolutely right. This is a problem that is now running very wide and very deep. I have not been looking at it for nearly as long as Jamie. My background, essentially, is that in the last 18 months I have been making three one‑hour documentaries for the BBC. We have been looking at many aspects of this very complex problem.
In particular, we have launched an initiative in Newcastle to try to get a city to come together and support each other to take action across a whole raft of areas. This has been, I would say, a modest success. We have not hit our targets. The model works, but I have found that it is incredibly hard. It is that issue of health inequality that is at the centre of the difficulty and we really have to pull a lot of levers. Jamie is absolutely right. Some single, headline‑grabbing piece of legislation or one or two moves by a couple of big companies is not going to do this.
Talk is always going to come out in this discussion about personal responsibility: how much is it down to individuals to change their behaviour, to change their diet, if they want to change their lives? I do not think human nature has changed in the last 30 years, but the obesity rates in this country have trebled.
Another thing that has undoubtedly changed is the food environment. We have seen an arms race between the big food brands competing with each other in a game they are extremely good at, backed by a huge amount of money. They are racing for our appetites, and we are, ultimately, the losers.
We have a big problem now, but I have seen that there are a lot of different levers to pull. There are a lot of areas where action can be taken for the better. I am right with Jamie, and we need to see all these levers being pulled. Chapter 2 should not be the prelude to chapters 3 and 4. Chapter 2 should be the “Let’s fix it now” chapter. Today is 1 May. This is mayday for the obesity crisis, and you can read the word “may” any way you like.
Chair: Great stuff.
Q41 Luciana Berger: Mr Oliver, just over a year ago a “Dispatches” programme on Channel 4 compared and contrasted what was intended to be in the Government’s obesity strategy and what actually ended up in the final plan that was published. There were a number of measures that did not make it into that final draft and you spoke about it on that programme—measures including a measurable pledge to cut childhood obesity and plans to force food outlets to put calorie counts on menus. That was scrapped. We saw plans to remove unhealthy food from check‑outs dropped, and one of the areas you are particularly focused on—plans to curb advertising of junk food—was ditched from that final plan.
At the time you said that the Government’s plan screams out that we don’t care. Have you changed your mind since then, and do you think that had that original draft been implemented we would be in a very different place today?
Jamie Oliver: If I may go back, I was lucky enough to be welcomed into the creation of that chapter 1 with Mr Cameron, and a year and a half before then had voiced the logic and the reasonableness of a sugary-drinks tax, those drinks being the single largest source of sugar that our kids and teenagers consume.
I knew there was a lot of work to be done. I felt along that whole journey that the room, the people in it and the way that Mr Cameron ran the room was really good, if I am honest, and I was impressed. Obviously, with everything that happened with the election and Brexit, the world changed a little.
What I saw come out the other end was a massive disappointment, but it was a massive disappointment in that I think we let British kids down and I think we let British parents down. But, you know what, I am optimistic about the new advisers—thank God we have new ones. They seem bright and enthusiastic, and I think they care. Our responsibility is to try to support them to get enough good stuff over the line with Mrs May.
I failed English at school. When I looked over the last childhood obesity strategy that was published, more than anything, as I know from going through the basics of “doing” words with my seven‑year‑old son, there were not many “doing” words in the plan. There was a lot of suggestion, a lot of “I would like” and a lot of the old rhetoric around personal responsibility and people who should do things.
The world has changed since then. On the cost of the NHS, as we creep towards 70 years, I think of what we could lose. With the concept of “strong and stable” and post Brexit and optimism and being a really productive island as bigger, more robust developing countries get stronger, I think now is possibly the moment to land what Hugh said: we need chapter 2 to have the fundamentals of 3, 4 and 5. It cannot be a bit part. The childhood obesity strategy involves everyone—the home, businesses and civic life. With a clear, bold and aspirational Government that have the capacity for longitudinal vision, we could land this.
May I just say—you may not know, but I hope you are aware—that I worked for a year and a half to get all the Opposition parties to agree to the fundamentals of what chapter 2 of a childhood obesity strategy would look like? We did get those signatures. It was not easy, but hopefully that might help to clear the political way so that Mrs May can do what is right. So, fingers crossed.
Q42 Dr Williams: I still work as a GP in an area of high deprivation, so I welcome your focus on inequalities and the unequal distribution of childhood obesity. My questions are going to be about the soft drinks industry levy, so there might be a chance to use your props.
In your submission you said that the levy is a fantastic policy that has already had an amazing impact. Will you elaborate on that for the Committee?
Jamie Oliver: When I stood before my teams and said, “We are going to spend a year and a half curating the logic of a tax in Britain,” can you imagine how disappointed my teams looked? That is what we did, and, through the documentary, we were able to force debate in Government. It was the only mandatory thing in the last strategy that came out. It is fantastic for a few reasons, if I may explain.
First, we have already seen a lowering of consumption of these drinks—win. When I first came to this Select Committee, this particular product had this much sugar in it and everyone was aghast, but what again I developed with my son was the numbers 12 and a teaspoon. That is what I felt busy British parents required to make quick, impulsive decisions. Labelling is tied up in EU politics, and one of the upsides of Brexit will be more controls over honesty in packaging and colour coding and finally having a language we can all agree on.
Bear in mind that the sugary drinks tax has only been active for one week. This has happened. What we have seen even in our first week is two out of three soft drinks companies reduce and reformulate. Having lived in a world of voluntary reduction and the Responsibility Deal, which largely did not work—it should have been the accountability deal—I think the tax acted as such and you saw turbocharge reformulation.
Ultimately with obesity and diet‑related disease, in its simplest form we have a problem with excess calories and energy in the atmosphere. That was one hell of a tax that made a difference straightaway. For anyone involved in industry and “Food Inc,” the reformulation of these calories allows consumers to do better without even knowing it—and that is really powerful, because most of us know that habit change is the hardest thing; it is a beautiful thing, but it is the hardest thing to achieve and promise.
There are two reasons why it is fantastic, and I know the word “fantastic” is strong. I fought tooth and nail for the moneys from this tax to be a progressive tax for good, and a tax for good means that you take it from Peter to pay Paul. Paul was education—it was primary schools—and this money was ring‑fenced. Although Mr Cameron hated the idea of hypothecation, we got it—thank you, Mr Osborne—and modelled it at about £600,000 to £1 billion originally. We never thought that the turbo-charge reformulation would happen, so it is a win‑win on both sides. It looks like about £250,000 of new money is going into schools for breakfast clubs and sports. I do not know about you, but that feels pretty good.
Lastly, on the concept of tax and the easy tabloid way of saying, “You are taxing the poor,” this is a tax for good. This is a tax for love. This is designed to protect and give to the most disadvantaged communities. Where this money goes will affect those communities more.
More than anything, it was the first time a British Government showed their steel. I do not think you need to overuse the tax whip, but it was symbolic to a decade—to a generation—and it was symbolic to have a Government that was watching science and data and delivering to protect British children. It was a fantastic tax and there is possibly some logic in how we expand it a little bit.
Q43 Dr Williams: That was going to be the next part of my question. First, Hugh, do you agree?
Hugh Fearnley-Whittingstall: I would not have done that if I did not agree with Jamie. He is absolutely right. The sugar tax has been important because it has broken the taboo of mandatory legislation with consequences, and that is making a huge difference. It has been really important as an education piece. The simple fact that everybody has talked about it, thought about it and looked at it has brought home the staggering amount of sugar that was in our drinks—that, frankly, still is in a lot of our drinks but there is less of it.
It means that some of the other things we might get to talk about today become possible. We can be bold. We can say, “We pulled that lever and it had an effect. What are the other levers that we can pull? Let’s go ahead and pull them.” Yes, I heartily endorse everything Jamie has just said.
Q44 Dr Williams: Jamie, you were going to say what is next. How could it be improved?
Jamie Oliver: I definitely do not think we should overuse taxing without really rigorous data and measurement, but there is some logic to opening it out to milk products. Some milk products are absolutely jam-packed full of additives and sugar but are currently outside of that taxing.
Hugh Fearnley-Whittingstall: We might as well give them their moment in the spotlight.
Q45 Chair: Jamie, it would also help for the transcript if you could say what they are and how many teaspoons of sugar are in them. You gave that fantastic visual example, but it would be nice to record what the difference in the teaspoons was in each of those products that you gave earlier.
Jamie Oliver: This is a bottle of strawberry Yazoo.
Hugh Fearnley-Whittingstall: This is a Mars milk drink in which we have 33 grams of sugar.
Jamie Oliver: Buddy hacked this one against EU legislation. It has nine teaspoons of total sugars.
Hugh Fearnley-Whittingstall: This is 10.
Jamie Oliver: I think it is logical and sensible to look at and interrogate whether they should be included. Based on the next year, it will be interesting to look at where, cleverly, the ratchet for taxing is placed, how close the industry falls underneath it and whether it needs a little tweaking. There is logic in that and it makes sense to me.
Q46 Dr Williams: In summary, you can see that not only is it changing the behaviour of producers, because they are put putting in less sugar, but information sharing is changing consumer behaviour.
Jamie Oliver: It is not just in drinks. I think that is because the Government stood up and were clear and bold. If I may roughly quote Mr Osborne: “How could I look at my children and say I did not do anything?”, if I remember right from his Budget speech. That was the energy he was putting across. That is a good energy and it is why I got up this morning and said goodbye to my kids to do today’s work. This concept of a multi‑pronged strategy should have a maternal heart.
Q47 Dr Williams: My final question is this. You mentioned how the income from the levy is being distributed. Are you confident that that income is being distributed in the right way in order to reduce inequalities?
Jamie Oliver: It is a brilliant question. One wants the Government to get the best bang for their buck. Currently the broad strokes are breakfast clubs and sports. It is kind of an open remit. We still do not really have clear nutritional standards on what is in the breakfast club, so that needs to be looked at to see what it entails.
If the money is going down, is it being subsidised by other parts of Government? I do not know. If it is going down because of the success of the reformulation, which is obviously of benefit, one wants to spend a pound in the right place. One does not want to water down the cash through success and then do a watered-down upside in schools. The best way to spend that money is to ask headteachers at primary schools; they will tell you where to spend it.
Q48 Dr Williams: Is there anything else you would like to add on the soft drinks industry levy?
Hugh Fearnley-Whittingstall: I am not sure to what extent the funds from the levy are ring‑fenced around school expenditure, but from what I have seen in Newcastle there is an enormous amount of scope for supporting communities in other ways—through cooking lessons and through food classes for kids in the community. There are so many willing people who could do amazing work with a little bit more funding. They have grassroots, seeded projects, which are brilliant, and were a joy to work alongside, but they could all do with a boost; they could all do with some help.
Q49 Dr Williams: We asked the previous panel about breastfeeding support because we all know the value of breastfeeding in reducing childhood obesity. We also know that there is a massive socioeconomic gradient in the uptake and maintenance of breastfeeding. Did that issue come up in your work in Newcastle?
Hugh Fearnley-Whittingstall: I cannot say that we have covered that story or that I have really come across it, but it is important work. It has to happen, yes.
Jamie Oliver: It is the eye of the storm and no one wants to talk about it. It has to be dealt with so sensitively; otherwise everyone beats each other up and no one wins. We are the worst breastfeeding country on the planet, and it is the beginning of the story—in actual fact, it isn’t, as the moment of conception is the beginning of the story.
Breastfeeding is an area that I am deeply passionate about but am constantly told to go nowhere near. The danger is that something as important as the childhood obesity strategy is ruined because of baggage and divisive subjects like that. It definitely needs to be dealt with. It kind of needs to be put in a box, funded and dealt with by local people and, ultimately, surrounded by love, support and no judgment, but I would say it is a No. 1 public health priority.
Dr Williams: You will find a lot of support for that approach from this Committee, I hope.
Q50 Dr Cameron: You have spoken already about the levy potentially being expanded to other types of drinks. What about food groups? Are there any obesogenic food groups that you think the levy could be expanded to include that would make a difference to the health of children?
Hugh Fearnley-Whittingstall: That is a tricky area. Jamie is right that we have to be very careful, that we have to use taxation in a very clear‑cut way. I would never say never, but what I would say about the foods that we know are difficult, especially for kids, is labelling. There is a lot of room for improvement in labelling and nutritional information.
We have issues over portion size, which is a big part of my programme that goes out tomorrow night, and there are big issues over traffic‑light labelling, particularly on sugar‑added breakfast cereals where we have seen two of the biggest cereal manufacturers in the world—Kellogg’s and Nestlé—bucking the healthy decision by almost all the supermarkets for their own‑brand cereals, which tend to track the products of the big brands. They will have a chocolate rice and some kind of multigrain hoop; they will have their version of all of these. The supermarket own brands, to their credit, have put clear traffic‑light labelling on. Until we began making our documentary, neither Nestlé nor Kellogg’s was doing that with their sugar‑added cereals.
We have drawn some attention to this. Nestlé has stepped up, Kellogg’s notably has not, but this is just one example of a point that Jamie has already made: that when it comes to clarity of labelling, nutritional information and portion size, if we do not get everybody playing the same game on the same level playing field, people are going to duck and dive and invent their own version of what a portion should be; they are going to present something in a skewed way that suits their purposes; and all that is going to mean is that parents trying to make healthy choices for their families will not get the clear, visible information they need.
We are getting there with traffic‑light labelling. Families are getting the hang of them. The red light, amber light and green light, after a certain amount of scepticism, even derision, have been there long enough that they are starting to matter.
We need to complete that job. We need to offer that up as a solid framework across the board, and here we get to something that is going to come up anyway: there need to be consequences for businesses that do not comply. You either make it absolutely mandatory or you make incentives for those who do and consequences for those who do not.
Q51 Dr Cameron: Do you have any comment, Mr Oliver?
Jamie Oliver: When I am looking at a campaign or a documentary, it is ultimately about how we protect British kids everywhere, especially the most disadvantaged communities, and how we help busy parents who are juggling a thousand and one things. The tax whip should be used very sparingly and, unless it has utter scientific clarity, like we had on sugary sweetened drinks, nuance certainly does not help us. Sometimes if you model taxing other foods—if you start dropping sugar but gaining fat—you can make the story twice as bad. I am yet to be convinced of other ways of doing it efficiently, but I think we are in a position where we can sit back and watch this.
This morning in Scotland we saw one other area that had science and data behind it—minimum pricing on alcohol: when you look at the evidence, you cannot argue with it. They are leading the way there.
Q52 Dr Cameron: Yes. We are very proud of that.
Supermarkets can play their role and some local supermarkets in my area have started an initiative where children have free fruit when they come into the store. This has helped greatly, not just myself, because it used always to be, “Can I have a sweet or crisps?” going round the store. Might that nudge children in the right direction in choices, even going round a supermarket?
Jamie Oliver: Certainly, from my experience, I have pushed free fruit in-store in various supermarkets in different countries with massive success. It also contributes to farming, waste and wonky vegetables—the fact that fruits and vegetables come in different shapes and sizes. It is the most old‑fashioned form of “try before you buy”, and, ultimately, we are living in a time where our kids are so brand aware and so marketed that the poor old vegetable and fruit industry does not really have much of a chance.
Physical, local initiatives, incentivisation and making it easy and a bit of fun is all power to helping our kids. British children and children on the planet are not put on earth to eat burgers and nuggets; it is not genetic. So, it is about normalisation and making it fun. I totally agree with you.
Hugh Fearnley-Whittingstall: I agree with that and I think we have to look at vegetables as well as fruit. Fruit sales are gently on the up in the UK. Vegetable sales are declining, and that is a very serious worry. We have to look at how we can get kids eating more vegetables. There is a whole education piece there. Thanks to the amazing work by Jamie, there is some provision for really good education about food as well as standards for school dinners. The two have been packaged together very effectively.
We do not have a lot of sight, though, of how well that is being delivered, particularly the education piece, and I think Ofsted needs to be assessing both the quality of school meals and the quality of food education. That is one way we can kick-start that.
I know we are going to come on to the subject of advertising—it would be insane if we did not—but I would like to put in a bid early on: when less than 1.2% of all the food advertising in the UK is focused on fruit and vegetables, you know something is wrong; you know we have to pull some levers to change that. That is not just going to be about curbing the negative effects of the avalanche of junk-food advertising that we are all forced to watch. It has to be about finding ways to promote the marketing and advertising of healthy foods—of vegetables in particular. If you break down that 1.2% of fruit and vegetables, the 1%, or more, is fruit; vegetables are almost nowhere to be seen in how they are promoted.
Yet these are the life‑giving foods. As Jamie says, these are the foods we were born and have evolved to have at the centre of our diet. If we are going to try to get back to a place where the nation’s diet is essentially the bedrock of good health rather than something that has started to make more people sick, fruit and vegetables are absolutely front and central.
Chair: That brings us neatly on to Johnny’s group of questions.
Q53 Johnny Mercer: We are looking at chapter 2, and you, Jamie, are looking for a fundamental dial‑shifter from the Government. Would you say that is advertising?
Jamie Oliver: It is about a fundamental change in putting advertising along with the other pillars of clarity, legislation, control, rigour, care, aspiration and measurement—yes, absolutely. Without question, it is, in my opinion, immoral not to have any view on the relentless advertising of high salt, fat and sugar products to kids.
If I may give some clarity, let us talk about traditional broadcasts. We already have standards that protect children until 6 o’clock at night. But that is not where the kids are. The kids, en masse, on terrestrial broadcast are watching “The X Factor”—1.2 million kids last week. If they watch a whole season of that, that is a junk‑food movie that they are going to consume and see in watching that traditional broadcast.
Should there be standards? Yes. Could those standards have a nutritional profile? Yes. Is it stopping Coke being advertised? No; they can just push their Coca‑Cola Zero and Diet Coke.
As for this concept that caring for British kids is going to compromise British drama, first, that is a weird conversation; and, secondly, it does not have to be like that. It can have rigour, structure and some science behind it. It is a little bit like a reformulation programme: it is not stopping advertising; it is slightly reformulating it.
At the same time, as important as that is symbolically, morally and literally, kids are not consuming most of their content from television. It is screens, it is phones and it is free apps and games. We have the Cambridge Analytica scandal at the moment and the concept of marketing directly to kids, which is wrong to me. It is really important that the British Government are not analogue in being all over this like a rash. It is a massively important area.
I spoke to Jimmy Wales from Wikipedia and messaged the two guys who invented Instagram yesterday. I know these people and they say, “If you can dream it, we can do it.” It is all doable. What we need from the Government is utter clarity on how and what does and does not get in.
We must not let the possibilities of data stop us doing the right thing. By the way, whatever looks good this year will change for next year anyway, so it needs to be set up with the intention that it will forever evolve and change. But is it okay to blatantly market junk food to our children? Right now, with the statistics, no, I am not having it. It is wrong.
That bounces on to the concept of BOGOFs—buy one, get one free. It all has to be about making real food cheaper and more available to British parents, especially the ones who are skint. That is the holy grail. BOGOFs do not work. We know they do not work. They make you buy more, eat more and waste more, and that costs more. Aldi and Lidl set their stall out making individual products cheaper. I get it. One needs to look at some of these strategies.
Q54 Johnny Mercer: Have you seen a country—I can think of Germany, for example, with its legislation around buy one get one free—with ideas that have really pricked your interest and made you think that this policy, brought over to the UK, would make a fundamental difference?
Jamie Oliver: If you are looking at the concept of deals and honesty on labelling, Chile is doing some of the most interesting things at the moment. You have to earn your way to a clear packet, instead of having to put it on the front. All the statistics are there. Have a look at their packaging; it is quite a good bit of work. Obviously, we cannot do that until post Brexit.
Again, like where we started, any of these ideas in their singularity are not going to deliver the goods. One does not want to be dramatic, but if you look at mortality—death—and productivity, I would say that this is a national security issue, without question. There is no British military or policing where the statistics get anywhere near the numbers on diet‑related disease.
Hugh Fearnley-Whittingstall: It costs more than the police. It costs more to treat type 2 diabetes and obesity‑related diseases than it does to run the police service, fire service and the judiciary in this country. Let us not be in any doubt about the scale and the significance. In the end, this is about solving a problem that frees up huge amounts of money and time to deal with problems that are less avoidable, because, as we are seeing, there are lots of ways to avoid what is happening.
Jamie Oliver: I do think that the concept of personal responsibility and choice is a really important one—
Q55 Johnny Mercer: This is what I wanted to ask you. What are you going to say to people who say that this is a nanny state and, “If I want to eat fat food, I will eat fat food. That is why I am British”?
Jamie Oliver: I believe in the British people—that, when given good, clear information, they largely make brilliant choices. We keep talking about the concept of choice when we largely do not have choice. If you go to a vending machine and there isn’t choice, you don’t have choice. If you go to a petrol station to get your lunch for the third time that week and you don’t have a choice, you don’t have a choice. If you go to a supermarket in a poor area and everything that is on BOGOF is unhealthy and bad for you and there are no deals on the healthier things, you do not have a choice.
It is important that we look at the morality of what is choice and, being very basic about it, even 50:50 would be fair. Even if there was legislation that said for every deal you do on junk food, there is one on fresh food, it would be fair. We do not even have that clarity yet.
Q56 Johnny Mercer: What do you think, Hugh?
Hugh Fearnley-Whittingstall: As I said, it is completely out of whack: 1.2% of the advertising spend is on the foods that we know are good for us, primary healthy foods—fruit and vegetables. The numbers are in. Cancer Research UK has done a study that demonstrates that children who have a good recall of television junk-food advertising consume more calories to the tune of one ad remembered per day equals 18,000 more calories per year. They have also shown that more deprived communities are more affected by junk-food adverts.
That is no great surprise because they are more targeted by junk-food adverts—take Chillingham Road in Newcastle: within barely half a mile, there are over 20 takeaways, and where there are advertising hoardings or bus stops with a space for an ad, you can bet it is going to be for junk food. There is very clear targeting of those who are at most risk and in the most deprived areas, so they are the ones who stand to benefit from these changes.
None of these things works decoupled or on their own. They have to be taken with education. To make great choices, we need great education about food. That has to be part of it. We have to build the whole thing with a long‑term view and not isolate these things. They all need to be blended.
Q57 Johnny Mercer: Finally, which bit is not getting through? We asked Simon Stevens if he could have a silver bullet for health, which is the defining challenge in my generation of politicians, what he would do. He said if he could do to obesity what he did to smoking it would cause the biggest fundamental shift. The trouble is that we kind of won that argument with smoking, but we are not quite getting there on obesity. What is it that is not accepted about food?
Jamie Oliver: But it took 40 years; that is the problem. Smoking took 40 years. We do not have 40 years to do this. We will not have an NHS in 40 years’ time if we do not get our heads around an environmental strategy that attacks ill health and protects child health. We have to look at the whole picture. I truly believe that. His sentiment is bang on, by the way, but may I reverse slightly? Can we talk about Tony the Tiger?
Q58 Johnny Mercer: What is that?
Jamie Oliver: On marketing—
Chair: Frosties.
Jamie Oliver: It is the use of cartoons and aspirational superheroes to peddle rubbish. I love a bit of Tony the Tiger and, like me, he is getting on a little bit. I think he feels pretty sorry for peddling very unhealthy breakfasts for a long time, but I do not want to make him redundant. I want to promote him. If he wants to promote porridge oats, Weetabix, Shreddies and anything that makes you glow when you walk to school, I am all in, I am all game, and all his superhero mates. You see newspapers going nuts about taking away Tony the Tiger. I love Tony as much as everyone else, but I would like to see aspirational figures that reel in our children, their eyes and their fantasy. I would like to see that used for good.
Hugh Fearnley-Whittingstall: I think we need a little bit of Tony the Tiger in the fruit and vegetable department as well. There is a smart bunch of people getting together at the moment, some of whom are renegades from the advertising and marketing industry. They are starting an idea—you will find it on crowd-funding sites—about funding adverts and really cleverly targeted marketing for healthy foods, for fruit and vegetables aimed at kids. Sir John Hegarty, the advertising guru, judged a competition that has set a ball rolling, which I think is very exciting. A lovely piece of creative work has come out of it, which was spread very successfully on social media a few weeks ago. It is not going to solve all the problems with one image, with one advert, but it is a nice piece of work with a kid holding up a couple of carrots next to his head, which throws a Batman‑like shadow against a wall.
Unexpectedly, not only did it successfully go viral but it had loads of people finding a pair of carrots and doing the same thing—and it spread. Schools were doing it and the Co‑op took it up and put some imagery on their tills. It is just the beginning.
There used to be a very successful milk marketing board, which the Government used to support. We need business people, creative people and Government to look at ways to support something that has an equal and opposite effect. It needs to be equal and opposite. That 1.2% spend cannot stay right down there. The creativity and the spend need to be massively more significant in positively promoting healthy food.
Q59 Johnny Mercer: I think that too—there is that side of it—but we need somehow to cross the divide to making it socially cool and more acceptable. If you are drink-driving—
Hugh Fearnley-Whittingstall: Are you saying it needs to be socially acceptable to eat carrots?
Q60 Johnny Mercer: No. I am saying it needs to be more socially unacceptable to be unhealthy, such as around drink-driving—that sort of campaign was won.
Hugh Fearnley-Whittingstall: Nobody really wants to be unhealthy.
Q61 Johnny Mercer: No, but I think people do not take obesity seriously enough and understand the dangers.
Hugh Fearnley-Whittingstall: It all boils down to a phrase that Jamie has coined before: we have to make the healthy choice a much easier choice. There are many ways to make that happen and we are covering some good ground today, but let us not pluck one: let us do them all, please.
Q62 Luciana Berger: I totally agree that it should not be piecemeal. We need the whole approach to what we are addressing and discussing today. Two other key elements form part of what we have touched on today, on which I know you both have expertise and about which it would be helpful for this Committee to hear.
Mr Fearnley‑Whittingstall, you have experience of the environment in supermarkets—you covered that in your programme. If you shared that with us, it would be helpful to hear what you think the key issues are.
Mr Oliver, you touched on the issues about what happens online and perhaps you will expand a bit more on what we need to address on advertising on the internet.
Hugh Fearnley-Whittingstall: On my first day’s filming in Newcastle I was “un‑launching” our initiative right in the city centre underneath the fantastic Grey’s Monument—a defining feature of the city—when a brilliant woman called Julie, who lives or was brought up in Walker, one of the more deprived areas of the city, came and gave me a bit of that: “You’re going to miss a lot here if you stand in the middle of the city talking to people who are passing by. Come and see where I grew up.” She took me to Church Walk, to a precinct that used to be a thriving shopping centre with several different food shops, a decent supermarket, grocers, butchers and all the traditional stuff. All that is left selling food is a small, independent shop with a very small section with a little bit of salad and a so‑called supermarket that does not sell any fresh fruit and vegetables.
We can talk about fresh‑food deserts: these foods are simply not there. One difficulty is that people are not necessarily shouting for them, but we have to find ways to make these foods more available, help people find them and help them know what to do with them. However hard that sounds—and you can tell how hard I find it; it is a really difficult thing—if we do not tackle that we are not going to get this right. We are going to be picking off easy wins around the edges.
We have to go to the heart of these communities to find out what the difficulty is, why so many people are not eating any fresh fruit and vegetables and how we can help them. We are talking primarily about an obesity strategy for the kids, and the focus has to be on raising a generation that is not suffering from the same problems as the current one. That also means we have to work with parents as they are now. The next generation of kids is going to be the next lot of parents, so we have to get that right.
You mentioned that you are a GP. One thing we have done—in Bristol, not Newcastle—is find out why it is so difficult for GPs and practice nurses to talk to patients about weight‑related illness, unless it is already really happening and you are saying, “You are going to have to lose this much weight before an operation.” How can GPs support families in a more preventive way? The conversation is not happening. How do we make it okay to talk about weight?
Professor Paul Aveyard at Oxford University has done a very interesting piece of work. If you weigh every patient who comes into a GP’s surgery routinely and keep a record of their weight and their BMI as a matter of their progressive medical record, as soon as you start doing that the conversation about weight within the surgery becomes much easier. That translates into outcomes. I get that what gets measured gets done; it has been measured and it needs to be done.
The GP surgery is one of the frontlines where we can support families, parents and their kids by not being afraid to ask the question and talk about this difficult subject. The way to do that is to make it routine. Understanding and knowing the weight of kids as they grow up, and of families as they turn up at the GP surgery, is basic and needs to be done.
Jamie Oliver: I will keep it pretty brief on digital. Ultimately, the concept of the digital ad space is driven by advertising departments like any other business—the capacity to focus on certain groups at certain times. Of course, most kids are using screens now and hand‑held devices. If they have to be 16 to join a platform, they tick yes when they are eight. It is not watertight, but we know through AI and algorithms and bits and pieces certain habits are blatantly showing what kind of group you are, and we know that is a fact. Without question, as we change regulation or legislation morally in one place, you will see it shift on to the other.
It is no surprise that, as the kids have started consuming most of their media on hand‑held devices, the money is following. Unpicking that, free games, as they might not have the purse strings to buy downloads, are riddled with all the predictables at issue. That was one motivation of some communication that I had yesterday on a platform, which was like “Can you do it?”, and it is all doable. If you can dream it, you can do it, and that is both sides. I completely endorse that and it bothers me as a father.
Q63 Diana Johnson: Mr Oliver, I want to ask you about choice because you describe how often people do not have choice. I was in the centre of Hull last Saturday and noticed a mum in the local bakers who wanted a sausage roll. The baker said she could have four for a pound, so she bought four; she had little kids and it was easy and straightforward to give the kids sausage rolls. We all know that sausage rolls are not great things to feed your children.
What you have been saying today about all these things that we need to do—that whole‑system approach—is great, but what would you say to that mum, who perhaps has her last pound to buy some sausage rolls, about the choice she is making?
Jamie Oliver: I love sausage rolls. You have hit on a really interesting thing. As any parent, there is a context of good nourishment and treats. What we have seen over the last 40 years is the concept of treats being normalised into nourishment. I grew up in a pub. I served Coke for a living; it was a treat. It is now hydration. And then you get into “Food Inc.” A sausage roll is a thing of beauty that should be loved and enjoyed like anything else, whether it is a bit of cake or a bit of chocolate. But the sausage roll you get today is not the same as it was 20 years ago. We are talking about meat content. The more meat you get, the less fat you get.
A really intelligent, grown‑up strategic childhood obesity strategy will be full of pillars that make moral sense, but behind those pillars need to be hundreds of lines about sensible stuff. For instance, the quantity of mincemeat that is out in the atmosphere is incredibly high—it is very economical—but can a little shift on fat content make all the difference? Yes. Can it make the difference to an area, to a town, to a family? Yes. We know that it is small amounts of calories that are going to total up over a number of years. This is where the argument with certain newspapers becomes very tough, in getting stuff over the line. They think it is just about a sausage roll, but it is not.
Going back to the Turkey Twizzler, which essentially was a sausage, it should have had four or five ingredients. But it had such a small amount of meat and added fat and skin that—and because it is a slurry of hideousness it had to be stabilised and coloured, with MSG to go with it—I think there were something like 45 or 49 ingredients. It was never about taking it away, because what happened? We created standards that did not exist for kids’ food in schools. What happened? They reformulated and guess what they gave you? A Turkey Twizzler with more meat in it.
My slight worry is the rhetoric around what is being taken away when actually this is about what we can give you more of. I do not think people should stop eating sausage rolls, but do I think that same mum should go back every single day and have a sausage roll? I think, no, and I think good old‑fashioned common sense would normally help you with that. Very possibly bakers like Greggs or a good local baker will diversify their choice as well.
Hugh Fearnley-Whittingstall: That is right. It is not just about the mum; it is about the retailer. It is about retailers—not just Greggs—having the imagination not to offer only four of one thing that they know people want. What is wrong with three sausage rolls and an apple or three sausage rolls and a small bag of carrot sticks? We have to create a culture. That may sound completely idiotic and maybe right now it does—maybe right now that sounds like nonsense—but we have to create a food culture where that is not nonsense, where that feels to a retailer like a smart thing to do.
Q64 Chair: The other point you highlighted in your documentary was being flogged chocolate when you went to buy a newspaper. Would you like to expand on your points about that?
Hugh Fearnley-Whittingstall: WH sugar—WH Smith—received a lot of social media during the transmission of that show. Again, this is a very difficult area to legislate, to say that stationers should not sell chocolate. I do not think we want to go there, but we are looking for a bigger sense of corporate responsibility, a bigger ambition to do the right thing on the part of big business.
Perhaps there is too much feeling that these kinds of actions are only ever going to hurt big businesses. But if you think about it in the long term, why would a business suffer from being seen to look after the health of its customers over the long term? We have seen this in a great piece of work pioneered by the Soil Association, the “Out to Lunch” campaign, which is featured in tomorrow night’s show, where they take 25 of the biggest named high-street restaurant brands—Pizza Hut, Wahaca, and I think Jamie’s Italian is on the list—and do something that is always a really good fillip for change for big business: they create a league table. They show who is at the top and who is at the bottom in healthy offerings, particularly for kids. Who is offering bottomless fizzy drinks where you pay once but you have as many different sugary drinks and, as long as you are there, your kids can have a free refill? Who has desserts with over 200 grams of sugar in a portion? I am sorry, it is not 200 grams, but they are off the scale—huge, piled‑up sugary desserts.
Q65 Chair: You would like to see clear league tables so that people can make those decisions.
Hugh Fearnley-Whittingstall: We want information on those menus to help families make the right choice, but we also want companies to aim higher. Let us create a race to the top; let us create ambitions to offer healthier things on the menu; and let us reward them when they do. When the league table is published, those that do will feel the benefit and get good press for it. Wetherspoons, which is not necessarily a name you would immediately associate with healthy eating, is in the top five of this league table. It has worked its way up there over the last few years and is very proud about it. I do not imagine it is doing its business any harm at all for the word to be out that fresh vegetables are offered as standard when kids come in and order off the kids’ menu.
Q66 Chair: Going back to that point you made about helping people to make the right choices, would you support, let us say, a ban on having the chicanes of sweets and crisps at the garage and other outlets?
Hugh Fearnley-Whittingstall: A ban is very difficult, if you are going to create a ban for one type of retailer. You cannot do it in the sweet shop, can you? You are not going to ban the sweet shop from selling sweets at the check‑out, so where do you draw the line—the newsagent? It is very hard. What you can do is say that big business, big corporations, should do the right thing, should step up and acknowledge the problem. Lots of the supermarkets have done it. A lot of the big supermarkets have taken away confectionery from the pester moment of prepaying at the check‑out.
Jamie Oliver: All I would add is that I do not think that the concept of taking away choice is one that we are passionate about, but there is a lot of upselling and script that is “memoed” out and strategically placed in businesses of many different types. That goes back to what Hugh was starting with: “Would you like this? Would you like that?” We started a dialogue a few years ago about whether it is morally okay that there are all those sweets at the check‑out when you have pester power and kids. The country said, “Yes, it is really annoying.”
I think that there is a line. You would not want to ban anything, but I think going to a place to get something with intention is one thing and knowing that at that point you are upselling or having kids annoy parents is done for a reason; there is science in the marketing behind it.
Q67 Martin Vickers: Before I go on to my question, may I come back on something you said in the last few minutes? We have spoken about the decline in the sale of vegetables. Mr Oliver, you spoke about having confidence in the British people: give them the facts and they will make the right decisions. It is over 30 or 40 years since the big supermarkets were involved to the extent that they are now and we have a vast array of fruit and vegetables available as soon as you walk in the door of a supermarket, 12 months of the year—the seasons have gone out now—yet you are saying there is a decline in the sales of vegetables. There does seem to be something of a contradiction, or are the British people so brainwashed by the advertising and the BOGOF specials that they cannot see through that?
Hugh Fearnley-Whittingstall: The fruit and vegetables in the supermarkets are lined up to look pretty tempting, but outside of the supermarket where are you seeing the urgency and the encouragement to buy these foods? You are not seeing it at all. You are overwhelmingly getting information and being bombarded with images of fast, unhealthy food.
Jamie Oliver: From my own personal experience, when we were telling the school dinners story and when I was working in Greenwich, in many schools we had the free fruit for schools scheme and you would see these fruits coming to school. They would not be eaten, but when you buy a £7 cutter that divides it, it all goes. The point I am making—metaphorically, I guess—is that making it easy and making it tempting, fun and delicious is definitely the way forward.
Even back in those days it was one of the most powerful things. A lot of kids had never tried a kiwi or a pineapple, and you only have to buy one pineapple for a whole class. We used to sit down once a week and do fruit of the week. That helped to get kids interested. I remember someone saying, “Look, my kid used to pester me for HARIBOs and now they are pestering me for some fruit.”
I think we can do better. Again, it is all about detail and tone, and some of that might be civic, some might be marketing and some is just back to parents to make things fun.
Q68 Martin Vickers: Moving on to the role of local government in advertising in particular and some of the proposals that came out of your Food Foundation, what role do you think local authorities should have? Should they take a much more draconian role in limiting advertising?
Jamie Oliver: There is so much to be excited about as far as devolved local powers, mayors and the nuance of “local” are concerned. I really do believe in that. There are amazing things happening around the country, and long may that continue. The idea of a multifaceted obesity strategy for the country is one thing, but I truly believe in allowing the nuance and entrepreneurial spirit of that locally. If anything, more powers need to be devolved and more funds given for them to do local initiatives. Having started Ministry of Food centres in many—I didn’t know about that one.
Chair: Someone has escaped.
Jamie Oliver: Do I carry on?
Chair: Yes, please.
Jamie Oliver: I have had Ministry of Food centres starting in Rotherham, Hull, Bradford and Geordie, where we give cooking lessons and nutrition and shopping advice to communities that are really struggling. We have trained about 80,000 people over the last 10 years, so I think there are loads of things that can be done.
With regard to advertising, for certain local cities it is within their gift to control advertising on their real estate.
Hugh Fearnley-Whittingstall: That is right, and to control the planning of new takeaways within close proximity to schools.
Chair: You want more powers for that. Unfortunately, the bell means that we are going to have to go to vote.
Jamie Oliver: That’s what it was.
Q69 Chair: We are almost at the end of our session. I am conscious that you may feel there are other things you would like to say, but, if not, we will close it there and say thank you very much.
Jamie Oliver: The only thing I was going to say—but the noise is quite annoying—was that I think local mayors and “local” can do amazing things. Sadiq Khan has already introduced a number of things and I am excited and hope that he will pull some more levers. I think that involves the junk-food advertising to kids in public transport where they know lots of kids are going to school. I am excited that he will launch some initiatives that might surprise us, so fingers crossed.
Hugh Fearnley-Whittingstall: Newcastle City Council is hungry for Government support to do all sorts of clever nudges in the city to create play streets for kids, to encourage people to walk up the steps in their Metro stations and to have the powers to restrict planning on new fast‑food outlets near school gates. There is lots of support for councils to do that kind of work. It is a massive part of the story.
Chair: Thank you so much for coming and sharing your thoughts today.
Hugh Fearnley-Whittingstall: Thank you.
Jamie Oliver: Thank you for having us. That bell is very frightening, isn’t it?
Hugh Fearnley-Whittingstall: Old school.
Sitting suspended for a Division in the House.
On resuming—
Examination of witnesses
Witnesses: Professor Jack Winkler, Dr Laura Johnson, Martin O’Connnell, Professor Franco Sassi and Dr Peter Scarborough.
Q70 Chair: Welcome to our final panel and thank you very much for your patience. I am sorry that we were disrupted by a vote in the Commons. For those following from outside the room, it would be very helpful if you could introduce yourselves and say whom you represent, starting with you, Dr Martin O’Connell, please?
Martin O’Connell: Sure. I am an economist and an associate director at the Institute for Fiscal Studies. I lead the research group that is focused on understanding consumer behaviour and firm pricing in retail markets. I have a bunch of work that is looking at the effect of Government interventions, things like tax policy, advertising restrictions on alcohol and food markets in particular.
Dr Johnson: I am Dr Laura Johnson. I am a senior lecturer at the University of Bristol. I am a researcher in public health nutrition and have done a range of studies following how diet relates to the development of obesity over the life course in children and so can speak to the potential effectiveness of targeting one food over another.
Professor Winkler: I am Jack Winkler. I was until recently the professor of nutrition policy at London Metropolitan University, but, more relevant to this particular group, I have been a founder, officer, member or consultant to virtually every health advocacy group you will have ever heard of, from the London Food Commission on right through to Action on Sugar today.
Dr Scarborough: I am Dr Peter Scarborough. I am associate professor at Oxford University where I work on population approaches to improve health, specifically through improving people’s diets. I am one of the researchers who is working on the NIHR‑funded projects to evaluate the sugar drinks industry levy.
Professor Sassi: Good afternoon. I am Franco Sassi. I am a professor of international health policy in economics at Imperial College Business School. I also have an affiliation, although I am on leave, with the Organisation for Economic Co‑operation and Development—the OECD—of which, of course, the UK is a member. I have had various roles with the World Health Organisation, particularly on fiscal policies.
Q71 Chair: Thank you. In this follow‑up and looking at chapter 2 of the childhood obesity strategy, we are trying to take a “What works?” approach. We are very interested in your evidence as to what you think are going to give us the greatest gains when it comes to tackling health inequality—the widening gap between the most deprived and the least deprived groups of children.
Dr Martin O’Connell, do you feel you would like to kick off with what you think absolutely should be there that is going to give us the greatest bang for our buck when it comes to delivering that goal of narrowing the gap?
Martin O'Connell: Sure. In very general terms, thinking about policy design in this area, it is very important that policies are both really well targeted at factors that are strongly associated with childhood obesity and that they do not create unintended negative consequences. We have to bear those two things in mind when thinking about policy design in this area.
In terms of specific measures, clearly there is an issue with trying to encourage people to understand the difference between healthy diet and healthy lifestyle and unhealthy diet and unhealthy lifestyle. So, interventions in schools that aim to educate children about what constitutes a good diet and the aims to introduce them to good-quality, healthy foods are a sensible place to start potentially, possibly also coupled with ensuring that there are fresh fruit and vegetables widely available in schools and at a price that people can afford—so, potentially targeted subsidies at schools that have a high fraction of deprived pupils. Those would all be sensible areas upon which to focus.
Q72 Chair: You mentioned targeted subsidies for schools. What about outside school and targeted subsidies that low‑income families can access?
Martin O'Connell: Yes. I think that also potentially has merit. Talking about subsidies, the targeting is very important. Sometimes you hear calls for general subsidies for healthy food products. That is likely to be very costly and also very poorly targeted. The kind of people who would benefit mostly from these general subsidies are likely to be people who already have relatively good diets and sufficient income in order to sustain them. However, well‑targeted subsidies, with a focus on low‑income families, for example, would have a role to play, potentially.
Dr Johnson: There are lots of really nice elements to the current strategy, especially the incentivisation of reformulation that has been incorporated in the soft drinks industry levy. But, broadly, what needs to happen in the future is that we need to target far more foods and we need to have a balance between restricting and trying to reduce the intake of unhealthy foods and encouraging the uptake and increased intake of healthier options as well.
With the current soft drinks industry levy, 87% of unhealthy foods that children eat are still not targeted by that, and there is still a lot of potential to expand that to things like chocolate, confectionery, biscuits, cakes and so on. Equally, we need to target encouraging the uptake of healthier foods such as fruits and vegetables for sure, but also high‑fibre breakfast cereals, breads, yoghurts and things like that.
The research we have done on the national diet and nutrition survey has highlighted that, if you add up the intake of all foods in a way that helps you explain major differences in the fat, fibre and energy density of diet—so, not any single nutrient alone—there are some key foods that come out of that score that can provide a priority list for targeting policy and intervention.
Q73 Chair: That is targeting policies to encourage people to eat more of them.
Dr Johnson: Yes. At one end we have a list of top five foods that we want to encourage, and at the other end we have a list of top five foods that we do not want to restrict but help people eat less of.
Professor Winkler: The next chapter in the childhood obesity plan should make clear an explicit objective not just to make the healthy choice the easier choice, but to make the healthy choice the cheaper choice. Doing that involves making use of a range of price instruments, which include taxation but are not limited to taxation. Let me give you a few examples.
The No. 1 ranked option in Public Health England’s list of policies on obesity, which was also ranked very highly in the McKinsey study, was control of promotions in retail establishments. Until recently, Britain had one of the highest rates of discounting in retail environments anywhere in Europe, and those were overwhelmingly for unhealthy foods. Getting some control over that would be my highest priority.
Secondly, the Government have a plan, and have had for at least 30 years, ever since I have been in the field, called the Government Buying Standards. It has made some progress but it has been chaotically, incompletely organised for decades. The Government are a major buyer of food. If they mobilised that buying power, they could have leverage to stimulate the reformulation of foods and make them cheaper in a very constructive way, but it requires an enormous amount of administrative co‑ordination.
The third option—which is the simplest one, the easiest one, with no legislation—is that we could simply adjust our VAT rates. We have differential VAT rates already. They are not aligned with health. It needs a thorough examination—there are people who are expert in this—of the options for simply adjusting differential VAT rates. It is the easiest option.
The final other option, which I mentioned in my paper, is to use the various agricultural price instruments as a way of influencing the mix and price of foods that we want people to eat. The very good analyses that I have referred to by Public Health England and McKinsey mention lots of options. They never mention agriculture.
The only person, in my knowledge, who has mentioned agriculture happens to be at the end of the table here, who, when he was at the OECD and wrote about obesity prevention, also mentioned using agricultural strategy.
Can I make one final practical point? We are concerned about the success of taxation and members of the Committee have asked whether it should be extended; milk drinks are one. May I make an unusual suggestion: extend it to chocolate. The reason is that all the big three monopoly companies in Britain, which are Nestlé, Mars and Mondelēz, already have made sugar‑free chocolate. They do not sell it in Britain. It sells freely in Germany; it sells commercially in Spain. In Singapore, which has a war on diabetes, Hershey has four sugar‑free chocolate products on sale that it does not offer on sale in the United Kingdom. A progressive, graduated tax, similar to the soft drinks industry levy, on chocolate would, I think, help and provide a stimulus to bring in reduced or sugar‑free chocolate to Britain.
Dr Scarborough: I will be brief and talk about what was in the childhood obesity plan and whether I think it is likely to be effective and likely to address inequalities.
To have a good policy that is going to have a big impact and address inequalities, you need something that is generally going to hit the entirety of the population and require very little agency of people to engage with the policy, because the more agency it requires, the more people are going to drop out, and that is likely to be socially graded.
In that regard, looking across at what was in the childhood obesity plan, you have measures such as the sugar drinks industry levy and the sugar reduction strategy, which require very little agency, so they are likely to be beneficial in reducing inequalities.
Altering the regulation of advertising and updating the nutrient profile model were mentioned. I am glad those are being looked at again, but I think it needs to be looked at in relation to extending the advertising ban to incorporate more TV time that children watch.
In terms of the ones that are unlikely to impact on inequalities because they require quite a lot of agency to get the benefit of the interventions, they are what has been mentioned about improving food labelling and developing new technologies so that people can have individual‑level devices that can help people change their behaviour.
Professor Sassi: Based on the research that I have carried out over the past 10 to 15 years, the approaches that work best are strong fiscal and regulatory approaches, of which there are not many in the current strategy. There is strong evidence of this and it cuts across different Government Departments’ policies in agriculture and transport, at industry level and so on. There are many regulatory and fiscal options that can be applied there.
What we know works less well, and in some cases does not work at all, are voluntary approaches, and there are many of these in the current strategy. They especially do not work very well when there is not a strong accountability framework, which at present is not there in the strategy.
There is mounting evidence, as Peter mentioned, about behavioural interventions, or what we call nudges. The evidence is particularly strong about default approaches or commitment devices that can help people make better decisions in their daily consumption, for instance.
There is also some evidence that primary care‑based approaches are useful, but for children we know, from a large amount of evidence, that only very few of these approaches work, so we need to be very selective in choosing the approaches that we want to implement as part of the strategy.
Q74 Andrew Selous: I want to go back to the area about which other food groups could possibly be encompassed in the levy that the Government have already brought in on sugary drinks. The Government monitor nine different types of food. You touched on that, Dr Johnson, earlier, but what is your view about how we should use tax policy for those other eight categories where we are monitoring sugar content?
Dr Johnson: I am not an expert on tax, so I will put that out there right now. I would not necessarily advocate as to whether tax is the right way to change food intake or not, but I definitely think that we need to target a broader range of foods, such as chocolate and confectionery, white bread, biscuits and cakes, and processed meat.
I think we can do that in a number of ways. I was quite impressed with what seems to be happening with the soft drinks industry levy, which is the reformulation effect. That is the aspect that has the most potential for impact on public health, and, as Peter said, it is one that requires the least agency for people. There is no active choice being made there; you are just helping people to improve their diet without involving a choice for them to make. There are lines of action to be taken maybe around portion control in chocolate, and possibly something else that could be done about bread, biscuits and cakes.
Q75 Andrew Selous: Dr O’Connell, from the IFS point of view, do you want to comment on tax?
Martin O'Connell: The case for extending the levy to include some of the high-sugar drinks, which are currently excluded, is pretty strong. Flavoured milk products and some fruit juices have sugar contents that are really very high and are comparable to some of the high‑sugar soft drinks. The current tax potentially creates a price differential between those excluded drinks and the included drinks. It may be that people are switching to them, and that response is not going to be particularly helpful because it is not going to lower their dietary sugar.
As far as extending the levy to other food groups is concerned, there is potentially a case for this, but I think we have to tread quite carefully. In the context of soft drinks, it is reasonably clear what the reformulation is going to be and what the switching is likely to be, replacing sugars with sweeteners. Food products, however, are more complicated from a nutritional point of view. They tend to include nutrients other than sugar. We would want to avoid reformulation or switching the results and sugar coming out of people’s diets, but it then being replaced by certain types of fats and salts, which potentially could also have poor consequences for people’s health and diet. That is not to say no, it is a bad idea, but we have to think very carefully about the design of the tax and about the evidence base before calling for it. I am not sure we are at that point.
Q76 Andrew Selous: Professor Winkler, you said, I think quite correctly, that we need to make the healthier choice easier and cheaper. Is part of enabling that to happen to make the unhealthier choices more expensive?
Professor Winkler: Yes. You do it both ways. You make the ones you do not want more expensive and the ones you do want less expensive. You can work on both ends at the same time.
Let me come back to your specific question. The reason why the soft drinks industry levy worked so well is that there was an easy and technically commercially socially acceptable form of reformulation that the soft drinks industry had been doing for 30 years already and they just speeded it up and hit the new targets. Reformulation to reduce sugar or other nutrients is more complex. It is more complex in other sweet products as well, but not impossible. A simple extension of the tax to, say, biscuits or cakes would not work anything like so effectively, but I have three specific candidates where I think it would work.
One is the other milk drinks that people have mentioned already. I mentioned chocolate because I know—because I have been in the industry for many years—that the products already exist and indeed are on sale. The issue with chocolate is another one related to taxation, which is marketing. Producing sugar‑free chocolate involves using sweeteners, and at the moment all the big three companies are frightened that introducing sweeteners into chocolate would be seen as some unhealthy intervention. They are acceptable in soft drinks but they are not yet acceptable in chocolate. We are at the situation that soft drinks were in in the 1980s, when Coca‑Cola first came to Britain with a product that had sweeteners in it and did not dare to call it Coca‑Cola; it was called TaB.
Q77 Andrew Selous: For those who do not have a medical background, including me, could you say a little about the health implications of sweeteners versus sugar, because to a lot of people following they both might sound problematic, so you are just swapping one bad thing for another?
Professor Winkler: Sweeteners are food chemicals, and it is always prudent to study interactions and long‑term effects. But they are the most studied food ingredients there have ever been for over a century and a half, and we have an enormous volume of evidence on both sugar and sweeteners. From what we know at the moment, the proven health risks of sugar are much greater than any potential health risks of sweeteners and, therefore, for most people, except those who have special medical conditions, a transfer from sugar to sweeteners would bring multiple health benefits. But—and this is important if you are considering taxation—there is, as you have correctly drawn attention to, an apprehension about sweeteners in the United Kingdom more than in many other countries in Europe, and that is what the chocolate companies are afraid of.
Q78 Andrew Selous: But is that not the role that Public Health England should take up and tell us that sweeteners may not be amazing, but they are much better for us than sugar?
Professor Winkler: Indeed, and, as it happens, Public Health England, among many other regulatory authorities, including the European Food Safety Authority, has approved sweeteners as a use unequivocally.
Q79 Chair: We on this Committee get quite a lot of correspondence asking whether we are just shifting people on to another unhealthy product. Have you seen any evidence that implies that any sweeteners are harmful to health?
Professor Winkler: With sweeteners, as in every single subject on nutrition, there are contrary views in circulation simultaneously based on apparently reputable research. I maintain a list of these contradictions, and sweeteners is among them. With sweeteners, however, the volume of evidence is enormous. They have been approved almost all over by more than 100 jurisdictions around the world. They have been approved by the Food and Drug Administration and the European Food Safety Authority—all over the world. There are a few exceptions and there is contradictory research, but every time any reputable authority has looked at the safety of sweeteners, they have approved them.
Professor Sassi: May I add to what Professor Winkler was saying on sweeteners? The point is not just about food safety and the safety of sweeteners. The argument that has been put forward by many scientists is that the use of sweeteners creates a taste for sweet products, for sweet food, which leads people to eat a sweeter diet more generally and it ends up creating an excess of sugar consumption in other parts of people’s diets.
The World Health Organisation has not yet taken a position on whether the substitution of sugary drinks with artificially sweetened drinks is appropriate or not. In fact, if you look at all the countries in the OECD area that have been taxing soft drinks, about half of them are taxing both sugar‑sweetened and artificially sweetened beverages, not just sugar‑sweetened beverages, as the UK is doing. I think the jury is still out on the question of whether the tax on soft drinks should be limited just to sugar‑sweetened beverages or extended to artificially sweetened beverages.
Professor Winkler: I must say that I disagree 100%.
Q80 Andrew Selous: Okay. Perhaps it might be helpful to have some clarity from Public Health England to reassure the public.
A final question from me on this area is what your thoughts are on what we use the tax revenue for from the soft drinks industry levy and other potential taxes, given that, if we want them to work, we are willing on a declining stream of tax revenue, and I could see that leading to problems if worthwhile projects were being funded with it. Do you have any thoughts on what we apply the revenue stream to?
Martin O'Connell: It is often the case with tax policy that the aim is to raise revenue and not to change behaviour. The soft drinks industry levy is not that kind of tax. The whole point of it is to try to modify behaviour, to encourage reformulation and reduce sugar in products, and also to encourage people to switch away from these products. We should not be concerned per se by the fact that the revenues from it are less than what was originally forecast. In fact, in some senses, this is a—
Andrew Selous: It is a mark of success.
Martin O'Connell: Yes. This is a mark of success. For sure, there may be a good case for spending Government revenues on investments in childhood health. That decision should be made independently of the revenues from the soft drinks industry levy. That should come out of general taxation. If that is a worthwhile investment to make, then do it. Do not artificially tie it to the revenues of a tax the whole point of which is not to raise revenue from.
Q81 Dr Williams: Still on the soft drinks industry levy, I am interested in the price differential and whether or not that is being passed on to consumers. Is it being passed on to consumers, and, if it is not in some cases, what does that mean for the policy?
Dr Scarborough: As someone who is on the evaluation board, it is far too early to make any definitive statements about how effective the sugar drinks industry levy has been or about how manufacturers are reacting to the sugar drinks industry levy and so forth. People seem to be very happy to say that it has prompted a whole load of reformulation. We have certainly seen a hell of a lot of press releases, and we know that the Government have scaled down their estimate of how much tax they are going to generate, but we do not know on what kind of evidence they have based that decision to scale down their taxes. We are collecting data to try to have a look at whether the announcement of the levy has prompted reformulation, and we do not have any definitive answers on that yet. That is all to come, basically. It is a bit early to go beyond that.
Similarly, with the idea about whether there has been a differential effect or whether the tax has been passed on, it is simply too early. The approach that we are going to take to have a look at this will look at an interrupted time series. I won’t go into the complicated details, but essentially you need a decent amount of data both before and after the intervention has been put in place, and we simply do not have that decent amount of data yet.
Purely anecdotally and looking at the way that things have happened straight afterwards, bearing in mind that things are going to change because the market changes all the time and things fluctuate quite a lot, we are yet to see that there is any evidence that the manufacturers are trying to retain price parity. It seems that the tax is being put on to sugar drinks and not on to diet drinks. That seems to be the early conclusion. As to the price fluctuations that we have seen, we could probably say that the drinks that have shifted around in price are the ones that are in the tax bands and the ones that have not shifted are not in the tax bands. That would concur with what we have seen elsewhere in the world, and generally you do get these taxes put on to the products where the taxes are aimed and generally the pass‑on rate is pretty high when it has been put on elsewhere in the world. But that is early and anecdotal, and not based on the evaluated data yet.
Professor Winkler: While I understand that the soft drinks evaluation team is a long‑term project, well-funded and I read everything they write, it is unduly rigorous to say that the soft drinks industry levy has not already had a major effect on reformulation. One can do that by walking into the shops and looking at the labelling or looking on websites, and you will find not just Ribena and Lucozade, which are two, but Coca‑Cola and Pepsi. You now have a listing of the sugar content of all their products.
I did a “before”—and I have now done an “after”—study on it. What has very clearly happened is that they have cut, for all the subsidiary brands, down to just below 5 so that, if you look at not just red Coca‑Cola but at them all—Sprite, Dr Pepper, Fanta, Oasis and Lilt—every one of the Coca‑Cola products has been cut to just below 5 to be tax free. That evidence is already there.
We do not know about the sales, but there is something more, and Peter mentioned it—price parity. Up until now, the major companies have always priced sugar-free and sugared drinks exactly the same. It is known in the trade as parity pricing, even though it costs them substantially less to make sugar‑free drinks.
Tam Fry and I will be presenting the Committee with a paper next week on the changes the tax has made to that, and while I look forward to the rigorous examination, the changes that it has made are already visible in the shops. I did a shop survey yesterday in preparation for coming and you will get the results next week.
Martin O'Connell: Can I make one last point on that? Typically, Government are not in the business of setting prices, but by designing tax in a sensible way they can have an influence and a bearing on the prices. The soft drinks industry levy tax is reasonably well structured—although it has some flaws—at precisely creating these price differentials, both due to the fact that it creates big tax differentials between low-sugar and relatively high-sugar products, and also the fact that it is levied as a specific rather than an ad valorem tax.
What I mean by that is VAT, which is a percentage of the price. That is an ad valorem tax, and it is pretty well established in the economics literature that having taxes that are specific, such as the soft drinks industry levy, are more likely to be passed through to consumer prices than are ad valorem taxes. That is another thing in favour of the tax, creating the kind of differentials that I guess you would like to see to incentivise people to switch from sugar.
Q82 Dr Williams: I am hearing very strongly that the reformulation is likely to be having an impact here, and that seems like a potential early success. But on a similar note I am interested in whether there is a risk, if there is a price differential, of inadvertently widening inequalities—a risk that people of lower incomes will just be paying more for high‑sugar drinks as a result of the tax. Is there any evidence of that?
Professor Sassi: I do not think there is formal evidence. Nothing has been published on this, except that we have made some calculations at Imperial College on that, because we published a paper in The Lancet only a few weeks ago on the distributional impacts—the equity impacts—of these taxes.
Essentially, people of low income will end up paying more in taxes than people of high income for the sugar industry levy, assuming that it is passed on to consumers. If you look at the actual amounts involved, we have calculated that essentially a low‑income family would spend in a year £8 extra compared with a high‑income family. So, of course, this is a higher tax burden for them, but whether that is something that the Government or Parliament should be concerned about is a different question.
Q83 Dr Williams: Is there any way in which the tax could be made smarter in the future perhaps by targeting it better to try to help it to reduce health inequalities in a smarter way?
Professor Sassi: The strength of this tax is precisely that it makes the people of low income change their behaviour disproportionately compared with people of high income, and these are the people who need to reduce their consumption the most. If we taper the tax for low‑income people to avoid them having to pay an extra £8 per year burden, then we would lose out on the health side, so I would not—
Q84 Dr Williams: So you strongly support keeping the tax the way that it is.
Professor Sassi: Yes.
Q85 Dr Williams: Peter, you are probably going to say at least in time for the evaluation to—
Dr Scarborough: Certainly at least in time for the evaluation, yes, to see how it has impacted and see if there is a differential that breaks out by income. Equally, by the nature of these taxes, they are going to be regressive. They are those kinds of taxes. It is the same as a smoking tax or an alcohol tax. With any kind of suggestion to try to conditionalise the tax so that it is not regressive, you are just going to lose either way, because you are either going to be saying, okay, you lose on the health inequalities, or, if you do it the other way and say the health inequalities really need a kind of boost so we will make the drinks more expensive for poor people, then it is not going to work that way either.
The way you can get round it is this, if people are really concerned. This would take a hell of a health impact assessment and a real kind of look around it. Revenue‑neutral scenarios in taxation in food end up progressive rather than regressive. The reason why they do is because lower-income families are more price sensitive, so they change their behaviour more than high‑income families. If you set up a situation where with any money that you generate from our taxation system you subsidise some other foods, the lower-income families are going to adjust their diet accordingly and end up with a cheaper budget, and that is going to be subsidised by the higher‑income families who do not change as much. That is how you address it if you choose to go down that route. That opens up a lot of questions, because subsidising foods is difficult and it would take a lot of health impact assessments to try to find appropriate scenarios to put things in place. But if there is a concern about the regressive nature, that would be the way to deal with it.
Q86 Dr Williams: That fits with the slogan that you began with—
Professor Winkler: Precisely.
Q87 Dr Williams: We needed to make the healthiest choices the cheapest choices.
Professor Winkler: That should be an explicit aim of this Committee. The paper that we will submit to you will make suggestions on how to bring that about.
Q88 Chair: As I said at the beginning, the whole purpose of this is that we want to focus on reducing the health inequality. What you are saying is that you are all in agreement that this is the best way forward.
Going back to that point about the nudge theory and helping people at the point of sale to choose a healthier product, the last time we held these hearings we heard views from some witnesses—the industry representatives—that the evidence from Mexico was not convincing; that there was no evidence of any change. Have we moved on? Has the evidence base from Mexico on price differentials changed in any way over the last couple of years?
Dr Scarborough: We now have two years of evaluated data from Mexico. Some of the concerns were that the tax would have only a short‑term effect perhaps, because people would see the price change but would quickly go back to their old habits. As of yet, there is no evidence that that is the case. The first year of the tax ended up with about an 8% decrease in sugary drinks, and then it went up to about 9% in the second year. I am not sure those figures are exactly right, but they are in that ballpark.
There has been a sustained effect on sugar drink sales and a sustained effect on differential prices within the system in the pass‑on rate that goes through. Yes, we know that it is producing a reduced consumption of these drinks, or reduced sales of these drinks, we should say. In so far as I am aware, that is as far as the Mexico evaluation has gone.
Professor Winkler: Excuse me, Franco. In a moment I would like to make a comment on Mexico in particular.
Professor Sassi: I want to add that the reduction has been greater in low‑income consumers in Mexico.
Q89 Chair: In your view, it supports the case for it being a good way of reducing the health inequality.
Professor Sassi: Absolutely, yes.
Professor Winkler: Can I just say that, in Britain, the only reports about the Mexican tax that one reads about are the ones done by Colchero and Popkin, and they have now done two? They make use of the Kantar Worldpanel as the basis for their study. Kantar Worldpanel is a very good system in some places, but it is very poor in a poor country called Mexico, and it is very bad in products that are bought on impulse called soft drinks. I made a count when they first came in of studies done on the Mexican tax. I gave up counting when I got up to 14. They are all done by interested parties using different methods. Some use the equivalents of the Kantar Worldpanel, some use sales data and some use revenue data.
You can get whatever result you want about the Mexican experience, and, frankly, I gave up because they are all tendentious, not least the ones that get most publicity by Colchero and Popkin. They are good, they are conscientious, and I know them. I know Popkin personally, but he is using the wrong database.
Chair: We do have to end shortly, but I am very keen to ask whether either of my colleagues want to bring in any further points before we finish.
Q90 Andrew Selous: I have a final question on the fat tax. We have touched on this area anyway, but, looking at two international comparisons in particular, I note that in France sweets, chocolates, margarine and vegetable fat attract VAT at 20.6%, while other foods only have VAT at 5.5%. In Canada, you have sales taxes on soft drinks, sweets and snack foods, but other foods are free from sales tax. I am also aware that a fat tax was brought in in Denmark but not really brought in in the right way and was abandoned.
Are there lessons for the UK from France, Canada and Denmark that we could apply in VAT or other areas?
Martin O'Connell: One point that has already been touched on by Jack is that the current system of VAT, as applied to food in the UK, is incoherent. A good starting point would be to sort it out. The fact that biscuits attract VAT and cakes do not, for example, has no real logical basis, either in terms of public health policy or simply on the principles of tax design. A very good starting point would be to focus energy on that.
In terms of introducing a fat tax or something, some of the comments I made previously about the extension of the sugar levy to other food groups would apply there. It perhaps is not the starting point, though, given that we already have a VAT system applied to food that is, put quite frankly, a mess.
Q91 Andrew Selous: Are there any other views from the panel?
Dr Johnson: Yes. I do not necessarily think that taxation is the only approach that we should be taking to deal with this issue. In general, foods do not have a lot of responsiveness to price in comparison to other products. They tend to have a less proportionate change in purchasing for a given increase in price. I do not know that that is the only option that we should be considering.
Our work has shown that out‑of‑home eating is particularly problematic, and there is potentially an opportunity to try a policy around incentivising eateries, fast‑food restaurants or cafes and things like that, where we know from our data that everyone eats more in those environments because of the types of foods on offer, possibly because of the choices being made there.
There was a really nice suggestion in one of the evidence submissions about the possibility of giving rate discounts for restaurants meeting criteria around the kind of food that they offer in their restaurants. Here what is key is not necessarily about restricting choice but balancing the choice that is available in those environments, because, across the board, people eat more of the unhealthy foods in those environments than they do at home.
Professor Sassi: On the Danish fat tax, that was discontinued not because it was ineffective but for political reasons. There was a change of Government and the lobby pressures were far too high for the new Government to keep the tax, basically. The evaluations that we have show that it has been effective. There has been some substitution into salty foods, which has been a concern from a heart-health point of view, but it has been an effective measure. It is a shame that it has been discontinued because it was an extremely interesting experiment that no other country has attempted. It is, of course, focused on saturated fat, which is clearly not a major factor in childhood obesity, but it is a potential candidate for taxation. It is a much more difficult tax to design than a soft drinks tax, of course, and that is why not many countries have been considering that.
Professor Winkler: Franco has just drawn attention to a critical point that has not been mentioned here but which is very relevant to a group of MPs. You have to think about the politics of taxation as well as the economics of it. The rejection, or the withdrawal, of the Danish tax was a political one, not an economically rational one, but taxes are not popular with voters. You have to think about it. That is why I went out of my way to try to think about other price instruments.
Chair: Thank you all very much for coming this afternoon and sharing your expertise.