Public Health England – Written evidence (NPS0125)

About Public Health England

Public Health England exists to protect and improve the nation’s health and wellbeing, and reduce health inequalities. We do this through world-leading science, research, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. We are an executive agency of the Department of Health and Social Care, and a distinct delivery organisation with operational autonomy. We provide government, local government, the NHS, Parliament, industry and the public with evidence-based professional, scientific and delivery expertise and support.

Contents

About Public Health England

1. Introduction

2. How can local delivery, including funding structures, of sport and recreation be improved to ensure that people of all ages and abilities are able to lead an active lifestyle?

3. How can children and young people be encouraged to participate in sport and recreation both at school and outside school, and lead an active lifestyle?

4. How can adults of all ages and backgrounds, particularly those from under-represented groups, including women and girls, ethnic minorities, disabled people, older people, and those from less affluent backgrounds, be encouraged to lead more active lifestyles?

5. Sporting Future: A New Strategy for an Active Nation

6. Is government capturing an accurate picture of how people participate in sport and recreation activities in its data collection? How could this be improved?

7. How can racism, homophobia, transphobia, misogyny and ableism in sport be tackled?

8. What are the opportunities and challenges facing elite sports in the UK and what can be done to make national sports governing bodies more accountable?

9. What successful policy interventions have other countries used to encourage people of all ages, backgrounds and abilities to participate in sport and recreation, and lead more active lifestyles?

10. Should there be a national plan for sport and recreation?

1. Introduction

1.1 This document has been prepared by Public Health England (PHE) in response to the House of Lords Select Committee inquiry on a National Plan for Sport and Recreation.

1.2 The United Kingdom (UK) Chief Medical Officers’ guidelines provide the benchmark for assessing population levels of physical activity.[[1]] Most adults aged 19-64 years report being active with levels of activity decreasing with age.[[2]][[3]] However, a substantive proportion of the population remain inactive and people from more deprived areas tend to be less active compared to people from less deprived areas. Less than half of children and young people meet the guidelines for physical activities.[[4]]

1.3 Disparities in physical activity patterns across society means that the health benefits of physical activity are not fully realised in England and that physical inactivity is likely to contribute to health inequalities. Evidence suggests, encouraging everyday physical activity, including walking and cycling, is the most effective way to improve individual, community, and whole population health and wellbeing[[5]].

1.4 PHE focuses its work on addressing health inequalities; this includes sections of society who, due to a variety of wider factors, are the least likely to be active/ have the highest levels of inactivity. PHE takes a whole systems approach to improving physical activity and engaging through local systems. In addition, PHE recognises that the significant contribution that Sports, Leisure and Recreation sectors all contribute to getting the nation active.

1.5 The necessary measures implemented to control the spread of COVID-19 have impacted the physical activity levels of adults[[6]][[7]] and children and young people[[8]][[9]]. However, this impact has not been felt equally and has disproportionately affected older people; people from lower social groups; people living with a disability; those with one or more long term condition, who were asked to shield; and people from Black, Asian and minority ethnic groups[[10]].

1.6 For this submission the following definitions for activity are used:

         Adults: Active (at least 150 minutes a week); Fairly active (an average of 30-149 minutes a week); Inactive (less than 30 minutes a week)

         Children and young people (CYP): Active (an average of at least 60 minutes a day); Fairly active (an average of 30-59 minutes a day); Less active (less than an average of 30 minutes a day).

2. How can local delivery, including funding structures, of sport and recreation be improved to ensure that people of all ages and abilities are able to lead an active lifestyle?

2.1 PHE has a role to support local authorities, the National Health Service (NHS) and their partners, to develop and implement place-based approaches to promote physical activity.

2.2 PHE co-developed with national and local stakeholders the Everybody Active Everyday (EAED) framework, which supports a whole system approach to physical activity through the following domains:

• Active Society - Change the social ‘norm’ to make physical activity the expectation
• Moving Professionals - Develop expertise and leadership within professionals and volunteers
• Active Environments - Create environments to support active lives
• Moving at Scale - Identify and up-scale successful programmes nationwide.

2.3 EAED aims to enable people to get more active and contribute towards improving the physical and mental health and reducing health inequalities across the population.

2.4 Following the publication of the Sporting Future Strategy in 2015[[11]], PHE and Sport England have developed a collaborative approach to deliver consistent public facing messaging; physical activity campaigns; local placed based approaches; and to develop and deliver the ‘Moving Healthcare Professionals Programme’ (MHPP)[[12]]. 

2.5 MHPP is enabling delivery of the ‘Moving Professionals’ part of EAED and aims to increase the capability, opportunity and motivation of healthcare professionals (HCP) to advocate and enable patients at risk of, or living with, health conditions, to get more active. MHPP is working with system partners to increase the knowledge and skills of HCP about the importance of physical activity; develop and test what works to upskill and enable HCP to advocate to patients the benefits of and ways to be physically activity; and to learn and understand how to design, implement and sustain at scale approaches to achieve integration within the health and public health system[[13]].

2.6 Through EAED, PHE advocates place-based, whole systems approaches and local authorities have demonstrated their unique ability to bring stakeholders together to promote physical activity and a healthier weight. PHE supports local authorities through evidence and practice-based tools, including place based approaches to address health inequalities [[14]]; Whole systems approaches to tackling obesity and promoting a healthier weight [[15]][[16]]; and Engaging NHS system leaders in whole systems approaches to physical activity[[17]].   PHE has also shared learning from the work on systems approaches and supported Sport England’s Local Delivery Pilot [[18]] programme, which has provided insight into what works to increase physical activity at the local level and the power of communities in delivering social and community outcomes.

2.7 PHE has developed evidence and practice-based tools to support the design and creation of healthier places, which can enable local communities to make use of their built and natural environment to get active. Improving access to green open space, encouraging walking, active travel, putting in place travel calming measures, neighbourhoods with access to amenities and cleaner air policies can help to create more inclusive opportunities[19]].

2.8 PHE regions collaborate and develop links with a wide range of stakeholders, including Active Partnerships, local authorities, the NHS and third sector organisations to support the local delivery of physical activity and sport initiatives. An example of local practice, Wellbeing Exeter, is a partnership of public, voluntary and community sector organisations who are supporting the 40% of patients who visit their General Practitioner with socially based rather than medical problems. Their approach offers social prescribing[[20]], for young people and adults in combination with asset-based community development[[21]] to enable individuals and communities to improve their health and wellbeing[[22]].

3. How can children and young people be encouraged to participate in sport and recreation both at school and outside school, and lead an active lifestyle?

3.1 PHE encourages active lifestyles in CYP through its social marketing campaigns, which directly support children and families with information, guidance and motivation to increase physical activity in CYP, such as Start4Life[[23]], School Zone[[24]] and Better Health[[25]].

3.2 PHE has also developed tools for schools and colleges, to support inactive pupils, address obesity, and reduce health inequalities. PHE’s ‘What works in schools and colleges to increase physical activity’[[26]] identified eight key principles of effective whole school approach, including engaging student voice, creating active environments, embedding in curriculum and promoting active travel.

3.3 Challenges around changing perceptions remain, which include schools not prioritising sports as part of their curriculum; or fear of traffic and road safety preventing CYP walking and cycling to school[[27]]. By understanding perspectives of schools and caregivers, PHE has, for example, been able to support Education, Health and Youth/Voluntary, community and social enterprise workforce with consistent physical activity messaging and support, through training including Making Every Contact Count[[28]] and the Healthy Child Programme[[29]]. PHE is also working with Department for Transport to influence the design of the built environment to breakdown some of the barriers to actively travelling to and from school[[30]].

3.4 PHE, through its work to support local authorities and with relevant organisations providing local approaches, is committed to ensuring effective duty of care and safeguarding standards are in place, including systems for reporting and learning from near misses and serious incidents, when it comes to children and vulnerable adults[[31]].

4. How can adults of all ages and backgrounds, particularly those from under-represented groups, including women and girls, ethnic minorities, disabled people, older people, and those from less affluent backgrounds, be encouraged to lead more active lifestyles?

4.1 PHE has developed and disseminated research emphasising the need to reduce health inequalities related to physical activity. Work relating to specific groups includes ‘Physical activity for general health benefits in disabled adults’[[32]] which shows the disparities in activity levels between disabled and non-disabled people and provides future research recommendations. Additionally, ‘Place-based approaches for health inequalities’ [[33]] highlights the need to understand the causes and costs of inequalities and provides a practical framework for action by the healthcare and public health system locally.

4.2 PHE is preparing research for publication which investigated the inequalities associated with physical activity across and within protected characteristic groups. The research, which will support national and local policy and practice, highlights a range of measures to enable people with protected characteristics to get more physically active, including: 

• Ensuring the physical activity sector workforce is diversely represented and suitably trained to challenge personal biases
• Working collaboratively with communities and allowing individuals to take ownership of what is being delivered
• Holding meaningful consultations with the targeted audience to build understanding of lived experiences
• Designing interventions which meet practical, environmental, social, and psychological individual needs
• Ensuring equality in physical activity is promoted prominently within commissioned healthcare services.

4.3 The response to the pandemic has exacerbated existing health inequalities[[34]][[35]] [[36]][[37]]. However, local authorities, NHS and the voluntary and community sector have acted to support vulnerable people and communities. For example, Tees Valley Sport provided free activity packs to promote physical activity among adolescents and adolescents living with a disability[[38]][[39]].

4.4 PHE’s Better Health campaign was launched in July 2020 to help support people to look after their physical and mental health. The overarching Better Health campaign focuses on all adults, but the different strands of the campaign target those most at risk. The obesity strand has a focus towards men aged over 40, people from lower socioeconomic backgrounds, Black, Asian and Minority Ethnic groups, and those living with long-term health conditions.

4.5 PHE has designated a higher proportion of media budget to produce specifically targeted communication to those in at risk communities.  The campaign has specifically taken steps to promote positive imagery, and to understand diverse perspectives by having representation from traditionally underrepresented groups including Black, Asian and Minority Ethnic groups, disabled people, older people and those with a BMI of more than 40, in focus groups and being promoted featured in campaign resources[[40]]. PHE has also translated much of the advertising into different languages, including Hindi, Bengali and Urdu.

4.6 PHE has also developed free apps and support increasing physical activity levels, Couch to 5K - a beginner running app with 4.8 million downloads since launch and 660,000 active users - and Active 10 walking app – which has 696,000 monthly active users [[41]].

4.7 As part of the Better Health campaign, PHE is offering adults free access to approximately 5000 different online classes, hosted by the following partners: Our Parks[[42]], Sport England[[43]], Instructor Live[[44]], Activity Alliance[[45]], Everyone Active[[46]], Better Leisure Centres[[47]], PureGym[[48]] and Her Spirit[[49]], among others. PHE has also collaborated with partners on local activation of national initiatives, such as ‘This Girl Can’[[50]], ’10-minute Shake Up’[[51]] and ‘The Daily Mile’[[52]], all of which have positively influenced attitudes towards physical activity specifically from groups less likely to be active. Campaigns such as these can further be improved by ensuring local areas have enough time to prepare and promote the messaging, including local opportunities for engagement in activities with local service providers.

4.8 PHE, in collaboration with Sheffield Hallam University, the National Centre for Sport and Exercise Medicine and Sport England, developed the Active at Home booklet[[53]] to provide practical guidance to older adults on home-based activities to maintain their strength and balance. It follows concerns that low levels of physical activity in older adults will lead to reduced fitness resulting in loss of independence and need for care in the future[[54]]. 250,000 printed booklets were distributed via Department for Environment, Food and Rural Affairs shielding boxes to shielding and vulnerable adults and a further 250,000 booklets were distributed via local authorities across England. Printed booklets were used because it was recognised that digital exclusion was an access barrier among the older adults age group.

4.9 PHE has supported Sport England in the We are the Undefeatable campaign[[55]] - led by 15 UK health and social care charities.  The campaign encourages people with health conditions to become more active and, during COVID-19, has provided support for being active at home.

5. Sporting Future: A New Strategy for an Active Nation

5.1 Since the publication of PHE’s EAED physical activity framework in 2014, and ‘Sporting Future’ in 2015, there has been renewed emphasis and increased action at a national and local level to develop population level and targeted approaches to deliver on these outcomes. Furthermore, the role physical activity has in maintaining health and preventing ill-health was recognised in the Government’s ‘Prevention Green Paper’[[56]].

5.2 In PHE’s view, the priorities, within the strategy remain relevant. However, there is an increased need to scale up action to support people and communities. This is due to the short and anticipated long term impact of the COVID-19 pandemic on people’s lives and activity levels. 

5.3 Building on learning from supporting local whole systems approaches and the review of EAED, it is evident that ‘how’ these elements and actions are designed and delivered in the future could benefit from a refresh by system leaders. Practice and evidence suggests aligning actions across organisational boundaries on priority issues, such as the environment, obesity, physical activity, delivering at scale through a whole system approach, and committing to sustained long-term leadership throughout the health and social care system, are necessary factors to consider. Connecting and integrating health improvement action where appropriate will help to address the social and environmental drivers pivotal to tackling health inequalities.

6. Is government capturing an accurate picture of how people participate in sport and recreation activities in its data collection? How could this be improved?

6.1 PHE uses data from Sport England’s Active Lives Survey and NHS Digital’s Health Survey for England to monitor the nation’s compliance with the UK Chief Medical Officers’ guidelines for physical activity. PHE uses this data and other evidence to inform public health policy and practice.

6.2 These surveys rely on members of the public recalling their participation in physical activity. In terms of improvements, objective measurement such as heart rate monitors, activity trackers and grip strength tests for muscle strengthening would place less reliance on recalling data from surveys. However, there would be additional costs to gather data in this way.

7. How can racism, homophobia, transphobia, misogyny and ableism in sport be tackled?

7.1 PHE maintains a no-tolerance policy towards racism, homophobia, transphobia, misogyny and ableism and is committed to work across Government to deliver equality and equity across the workplace and public health community at-large. PHE recognises that positive practice exists to deliver equality, and we support organisations and campaigns who demonstrate this, including, but not limited to:

• Sporting Equals[xlii] – promoting greater involvement and ethnic diversity in sport and physical activity
• Pride Sports[xliii] and Stonewall[xliv] – challenging homophobia, biphobia and transphobia in sport and improving access to sport for lesbian, gay, bisexual and transgender people
• Women in Sport[xlv] – promoting equal opportunities for women across sport and physical activity.
• Activity Alliance[xlvi] – supporting more disabled people to be active.

8. What are the opportunities and challenges facing elite sports in the UK and what can be done to make national sports governing bodies more accountable?

8.1   During the COVID-19 response, PHE, in collaboration with Department for Digital, Culture, Media and Sport (DCMS), provided expertise and guidance to European Tour Golf[[57]], to enable them to successfully run 12 international golf events in the United Kingdom, including the Women’s Open and BMW Professional Golfers Association. These events concluded safely and in accordance with COVID-restrictions. Wider benefits included contribution to the training of sports and exercise medicine doctors, the raising of a significant amount of money for health-related charitable causes through the Golf for Good initiative, and the dissemination of positive public health messages related to COVID-19, mental health and wellbeing, and physical activity, by the international golf players and broadcast partners.

8.2   At the grassroot and recreational level, individuals involved in elite sport embedded in their local communities can, through role modelling, facilitate the practical aspects of behaviour change to make it a reality. The COVID-19 response has many examples of strengthened relationships between elite sport and local communities and national governing bodies (NGBs) should continue to support.     

8.3   The work on COVID-19 has emphasised the economic disparity between male and female elite tiers of competition. Many male elite competitions have returned, but their female equivalents have not. This is due in part to the expense and staffing required for the introduction of adequate protocols, alongside the semi-professional or amateur nature of female sports. NGBs should be made accountable for addressing this. In football, financial disparities allowed the male game to return well in advance of the female game. PHE recognises that DCMS is committed to helping women’s sport come out of the current crisis and is working closely with the sport sector and NGBs to ensure this happens.

9. What successful policy interventions have other countries used to encourage people of all ages, backgrounds and abilities to participate in sport and recreation, and lead more active lifestyles?

9.1   Several countries have used interventions to encourage active lifestyles, with many focusing on the relationship between improving the built environment and increased uptake in active travel. [[58]][[59]] These interventions often target other public health objectives alongside increasing activity, such as reducing air pollution and using urban planning to provide opportunities for walking and cycling.

9.2   For example, cycling to school to improve air quality in Nantes, France. In order to reduce air pollution and traffic jams in school surroundings and to improve children’s physical condition, independence and traffic safety along school routes, cycling school “buses” or Vélobus were introduced in Nantes[[60]]. A Vélobus is a small group of children who cycle along a known school route under the guidance of an adult. Like a real bus, fixed routes and stops are called at.

9.3   Another example is the City of Amsterdam is taking various measures to make cycling safer and more accessible[[61]]. With a total investment of €54 million, they adapted city infrastructure by making cycle paths wider and smoother, increasing access to bicycle parking areas, creating cycle bridges and ferry lines over the river, and introducing traffic calming measures. As a consequence of these interventions, cycling has become more closely integrated into healthy lifestyle in the city; between 2010 and 2015, Amsterdam residents were cycling around 300 million kilometres more in total each year, there were 50,000 fewer sick days, and 40,000 fewer tons of carbon dioxide omissions were produced. Taking inspiration from this successful policy intervention, London has invested over £90 million over five years to implement similar infrastructure changes throughout Enfield, Kingston and Waltham Forest[[62]].

9.4   With evidence demonstrating that the popularity of cycling and walking has never been higher, the development of international interventions has provided learning for national policy[[63]].

10. Should there be a national plan for sport and recreation?

10.1        Yes. The impact of the pandemic on places, local institutions and assets, and most particularly people, including their physical and mental health has reaffirmed the need for a joined up, long-term systemic approach to enable diversity and inclusivity in physical activity, including sport at a national and local level. The implementation of any plan needs to take an integrated, whole system approach with action across sectors and which aligns and connects practice within healthcare, public health and social care. It should prioritise enabling those children and adults with the most to benefit from being more active. This includes people living in the country’s most deprived areas; people from Black, Asian and Minority Ethnic communities; people with disabilities; and people living with long term conditions. 

10.2        Moreover, there is a positive economic case for investing in services and an environment which promotes physical activity[[64]]. Investment and support for leisure and recreation sector following impact of the COVID19 pandemic is essential to ensure people have access to local leisure and sport facilities, swimming pools and play facilities for children and young people. There is a real possibility that a significant number of facilities in areas which support those in greatest need are at significant risk of permanent closure, thus further widening the health inequalities gap that already exists[[65]][[66]]. PHE has contributed to guidance on the reopening of leisure facilities.

10.3        PHE is keen to use learning from the Five-year review of Everybody Active Every Day, to engage in further conversation with stakeholders, including Sport England, to develop what and how the future national health improvement role needs to do to support everybody to be active, every day and amplify action in places and with communities.

29 January 2021