With this it will be convenient to discuss the following amendments: No. 169, in clause 132, page 86, line 41, leave out ‘junior’ and insert ‘primary’.
No. 170, in clause 132, page 87, line 3, after ‘the’, insert ‘annual’.
No. 171, in clause 132, page 87, line 3, leave out ‘junior’ and insert ‘primary’.
No. 176, in clause 132, page 87, line 32, at end insert—
‘(1A) Information authorised in accordance with sub-paragraph (1)(c) shall include information relating to a child’s body mass index.’.
No. 172, in clause 133, page 88, line 7, after ‘the’, insert ‘annual’.
No. 173, in clause 133, page 88, line 7, leave out ‘junior’ and insert ‘primary’.
No. 174, in clause 133, page 88, line 11, after ‘the’, insert ‘annual’.
No. 175, in clause 133, page 88, line 11, leave out ‘junior’ and insert ‘primary’.
No. 177, in clause 133, page 88, line 40, at end insert—
‘(1A) Information authorised in accordance with sub-paragraph (1)(c) shall include information relating to a child’s body mass index.’.
This is a timely debate, given that we had the paper on obesity yesterday. The obesity problem could be tackled in part by keeping a closer eye on schools, so that children who were developing patterns of obesity could be identified at an early stage and appropriate action could be taken, whether that involved educating the parents or whatever.
Currently, as a function of the national child measurement programme, children have their height and weight measured in reception and in year 6. The Bill appears to give the Secretary of State the power to increase the frequency of those measurements, but the Minister is not being bold enough, so these amendments are an attempt to provide something more meaningful.
Amendment Nos. 168, 170, 172 and 174 would provide for annual measurements of weight, so that weight could be tracked. I have also tabled amendments that would change the designation of junior school to primary school, so that the clause covered all children between 4 and 11 years old.
We also tabled amendment Nos. 176 and 177, which would specify that the information that is provided to parents includes
“information relating to a child’s body mass index”.
That is important because height and weight in themselves are not accurate enough measurements. They give a picture, but some children have growth spurts, for example, and any problem would be less easy to identify. The American Academy of Pediatrics has placed frequent measurement as its first priority in the identification and management of obesity. The academy’s research stressed to every doctor the importance of a yearly assessment for children. If body mass index were tracked from year to year, it would be easier to identify any early deviation from the normal, expected growth curve.
Body mass index is not something that most people can calculate off the top of their heads, but there are easy sliding scales and mini calculators, so it can be done at the touch of a button or the turn of a dial. Once a school nurse, say, has the height and weight measurement, it would be easy for them to provide the extra information. People could plot the information on hand-held growth charts so that they had a history over time. A one off measurement of height, weight or BMI is, in fact, fairly useless—all one can do by measuring that trend is to get an overall picture of whether 11-year-olds are getting larger and fatter. That may help to provide national statistics, but we are trying to produce something that will help to identify children who are at risk so that appropriate action can be taken.
I hope that the Minister will look kindly on the amendments. He has not looked kindly on any amendment so far, but I live in hope—I am eternally optimistic. I do not think that we should get too bogged down in whether people understand the concept of BMI; it is a fairly simple idea and can be explained to people. They do not need to know the calculation or anything else, but it is important that they are able to track the trends. My children are too old to benefit from such a measure now, but perhaps I will be a grandmother one day, and I would like to think that someone would keep an eye on my grandchildren.
I congratulate the hon. Lady on finally using the word “fat”—it is not used very often these days. My issue with the word is that “fat” is something for which a person might feel that they have responsibility, whereas they might think that “obesity” simply happens to them. I feel like a victim because of the extra stone and a half that I carry, but if I thought about it as “fatness”, I might take more personal responsibility for getting rid of it.
I appreciate the hon. Lady’s sentiments. I do not know about the use of the words “junior” or “primary”, but I dare say that there is a legal definition. We could use numbers or simply a term such as 9 to 10-year-olds. I do not believe that inserting the word “annual” would be terribly useful because, in fact, it might be useful to weigh and measure people monthly. There needs to be quite a lot of leeway for those who would be involved in the programme.
I intervene to clarify the use of the word “annual”. It would ensure an annual weight check for everybody—for all children. I fully accept that there may be a need for more frequent measurements in some individual cases, but specifying a more frequent measurement would be over-prescriptive on the health service.
Amendments Nos. 168, 170, 172 and 174 make explicit provision for weighing and measuring to be carried out annually. In England, the National Child Measurement Programme is currently run on an annual basis, with children in the reception year and year six being weighed and measured at any time during the school year. I am happy to confirm that we have every intention of continuing to collect that data annually. However, we do not think that the frequency of the programme needs to be specified in the Bill, indeed, that could cause potential confusion as existing guidance already asks primary care trusts to weigh and measure the children in reception and year six each year. PCTs are able to carry out that task over the course of the school year, which allows for the local health care professionals involved to be used most effectively, spreading their duties over the year and visiting schools at the time that best fits in with school activities and causes least disruption.
I am not sure why that would cause confusion. The Minister mentions a scheme in which, at some stage during the school year, children in reception and year six are measured. This measure is an entirely different proposition and suggests that each year all children will be measured. It is not so that they can be measured at any random time, the aim is to provide an annual health check for each child in Britain.
I beg the hon. Lady’s pardon, I misunderstood. I have explained why we believe the amendment to be flawed, but I misunderstood her reasons for tabling it. We do not take the view that it is justified or proportionate to measure every child every year. Measurements from these two different years will give us a pretty comprehensive database without imposing disproportionate burdens either on PCTs or schools.
It would be interesting to know if the Minister has any data so far. The scheme has only been going for four or five years, so he may not have any, but we do not yet know how far adrift children have been allowed to go in six years. It is a considerable period of time during which a child may have picked up bad eating habits. Yesterday we discussed how children do not always get the best food at home and how lunch boxes are not always healthy. Despite efforts being made with school meals and cooking, a lot of damage could have been done during that time. It is not about recording data, it is about identifying early problems.
That implies that the only way of identifying those problems is through weighing and measuring. As the hon. Lady knows, there are a range of measures taken by schools and by doctors and nurses so that they are able to intervene in this. Our advice suggests very strongly that, as things stand, annual weighing and measuring would not be justified in terms of the benefits compared to the costs.
Amendments Nos. 169, 173 and 175 would make the scope of the provisions in clauses 132 and 133 apply to primary pupils instead of junior pupils. There is a technical reason why we have used “junior”. It goes back to the Education Act 1996, where
“junior pupil” means a child who has not attained the age of 12”.
Primary pupil, however, is not defined, and unless accompanied by a suitable description, the amendment would use a term in statute without a clear definition. The main difficulty with that approach is that it risks excluding those children aged 10 or 11 who attend middle schools rather than primary schools.
On amendments Nos. 176 and 177 on the body mass index, as the hon. Lady will appreciate from the letter I sent her at the end of November last year, we have not ruled out providing parents with their child’s BMI but we believe that further work is required before we can be certain exactly what should be prescribed. That will be debated again when we come to discuss the regulations. An important reason why we may decide not to include BMI information is that recent research suggests a lack of understanding about it. We need to be sure that the information we provide is in a form that can be most readily understood and used by parents. Research commissioned as recently as 2007, from the British Market Research Bureau, on parental attitudes to the current weighing and measuring programme in England suggests that most parents do not understand BMI. Some parents said that they had never even heard the term used before and others, who had heard the term, said that they did not understand what it meant.
While the debate has focused on weight gain, in terms of a child’s health, I wonder what thought the Minister has given to girls approaching puberty. We know that increasingly, some of them suffer from anorexia and bulimia at quite a young age and the idea that suddenly their parents are going to start encouraging them, as a result of a statistic, to dramatically lose weight would give me some cause for concern. Although in terms of children’s health weight gain is a problem, so too is the increasing problem of how we handle young girls who become much more fashion conscious, even at primary school level, and for whom getting the balance right in how that information is given will need to be sensitively handled.
The hon. Lady is absolutely right. Sometimes we are better to talk about a healthy weight, because she is right to point to the problems of anorexia among teenage girls in particular, at a slightly later stage than the one we are discussing now. We agree that we need to move away, over time, from focusing solely on obesity to focusing on a healthy weight and healthy lives.
May I say to the hon. Gentleman, I do not think that we must assume that this is a problem just in the teenage years? Increasingly, it is younger and I know of many nine, 10 and 11-year-olds who are fans of the Sugababes and others, who are now fashion conscious even at primary school level, and for whom the argument would apply.
Yes, indeed and as part of the national child measurement programme we will advise school nurses or other health professionals who are concerned about a child’s health or weight that whether the child is overweight or underweight, they should take action accordingly through the local care and support that is available.
As I was saying, one of the reasons why we think that BMI may not be the appropriate way to give information to parents is that they do not understand it. Another reason is that as a single measurement, it may not as accurate in young children as it is in adults and I am advised that there are a number of reasons for that. Unlike adults, children are still growing and therefore one single measurement may be skewed by a particular growth phase, in particular BMI may vary with puberty. Secondly, evidence linking children’s BMI to health outcomes is not as strong or well established as it is for adults. We will be consulting parents, professional groups and other relevant organisations over the next few months, to develop the best system and format for providing children’s results to their parents. That will include determining what level of detail parents would find most helpful. In due course, we will consult further on the regulations around this measure, so all who have a view will be able to contribute to that debate. I have already sent the draft of the regulations to the Committee. I hope that in the light of those assurances, the hon. Member for Romsey will feel able to withdraw her amendments.
I listened with interest and disappointment to the Minister’s remarks. To return to the point about BMI, it is slightly different in children but I think that the Minister was being uncharacteristically feeble when he said that parents do not understand it—whatever happened to education? We do not have to call it a body mass index, we can call it something else, such as a healthy weight index, but it is a cop out to say, “Oh, this looks a bit difficult, we won’t do it this way” if it does prove to be the most effective measurement.
Yes, I have considered the use of centile charts and, having been reduced to a nervous wreck by a health visitor because my child was at the bottom of the curve, am not terribly enthusiastic about them. The BMI gets round some of those problems. I was interested to hear what the hon. Member for Tiverton and Honiton said because I have a naturally-skinny daughter who has always been slim, although she ate like a horse and has a healthy body image. She was constantly being asked by school nurses if she felt that she looked fat. Clearly, they thought that she was potentially underweight. If that had been tracked for a longer period, they would have realised that that was just her and that some people fall at the extremes of those measurements quite naturally.
An obsession with weight can be unhelpful for a fit and muscly child who will always be at the top of the scale, and it is a difficult one to judge. However, annual weighing would help to pick up early signs of decreasing BMI, which can also give cause for concern. Obviously, that would be treated in a different way. I shall turn my attention to the regulations and beg to ask leave to withdraw the amendment.
I could not help but notice the Minister’s eyes go up to heaven when I mentioned the possibility of a stand part debate. We started this morning’s sitting with everyone feeling a little tetchy, but I think that the mood of the Committee has improved. I would hate to see the Minister’s emotional state regress as a result of a stand part debate because this is important.
Obesity is probably one of the most important public health issues that we face. I understand that we are the first generation of adults whose children are likely to have a lower life expectancy than us. In this century, it is absolutely appalling to think that what we are doing will shorten our children’s lives.
I have a few issues that I would like to raise. I am not entirely sure why there has to be legislation on this matter. I saw the regulations and would like to thank the Minister because, although they are neither lengthy nor exhaustive, they give some idea of the thinking on that. They state:
“An important effect of the Regulations is to protect the position of the young children participating in the NCMP in compliance with the European Convention on Human Rights and data protection legislation.”
I assume, therefore, that that has to be placed in legislation simply to allow the PCTs to relay the information to the parents, but I would like the Minister’s clarification because at the moment that is already ongoing. I have had contact with all the strategic health authorities, which are all advancing well towards meeting their targets for that programme.
One of the issues that we should start with is just how fat we all are, and the figures are absolutely dreadful. The Department of Health’s website advises that the proportion of children in England aged two to 10 who were overweight or obese in 2005 was 31 per cent., compared to 22.7 per cent. in 1995. The proportion of children who are overweight increased from 12.8 per cent over that period to 14.2 per cent, while the proportion of obese children rose from 9.9 per cent. to 16.8 per cent. over the same period. In 2005, the prevalence of obesity for boys and girls aged two to 10 was similar: for boys, obesity rose from 9.6 per cent. in 1995 to 16.9 per cent. in 2005, while for girls, obesity rose from 10.3 per cent. to 16.8 per cent.
I also have some figures from Yorkshire and Humber. In fact, I congratulate the strategic health authority there on giving me such a detailed breakdown of what is going on. This will distress my hon. Friend the Member for Tiverton and Honiton, but it suggests that young people in the region eat only half the recommended portion of fruit and vegetables. It is projected that 33 per cent. of boys and 30 per cent. of girls will be overweight by 2010.
The figures for those aged 11 to 15 are even more stark. The projected level for boys is 33 per cent., and the projected level for girls is the highest in England. Some 28 per cent. of girls are projected to be obese, with a further 16 per cent. being overweight by 2010, which means that almost half the children in that region aged between 11 to 15 will be obese. That is truly shocking.
My hon. Friend raised the issue of anorexia. It is important to note that the flipside to obesity is anorexia. She is right to say that the issue affects younger and younger children. Sadly, though, that issue and the issue of obesity cannot be addressed simply by weighing and measuring them.
I would like to reinforce the points made by my hon. Friends the Members for Guildford and for Tiverton and Honiton. Because of the increased evidence of obesity and anorexia appearing at a much younger age, the clues that one gets for the trend starting are that much smaller. The sooner that the trend lines can be picked up, the sooner one can get the evidence, which will lead to better health advice and hopefully to a better outcome. That is another reason for saying the younger the better when it comes to applying this measure.
My hon. Friend raises a crucial point. It is all about picking up the trend. Early intervention is important for children suffering from anorexia and bulimia. It is not nutritional advice that such children need but psychological help. Looking at the figures on what is being spent on obesity drugs, one can see that they are now the fastest growing item being prescribed. Prescriptions for obesity drugs increased 28 per cent. with a total cost of nearly £50 million. I know that the Government are keen to address the drugs budget. In some ways it is a shame that we are having to treat such conditions with drugs because we have not acted at an earlier stage and tried to treat the condition with a lifestyle change.
The burden of the proposed measure will largely fall on school nurses from primary care trusts. The nurses will oversee the weighing and measuring. Schools will be asked to provide the PCT staff with a list of children to be weighed and measured and to inform the PCT if the parents have chosen to opt out of the programme. Information about individual children’s weights or heights will not automatically be given to parents, although they may request the child’s information. The records of children’s heights and weights will be anonymised and the data used in the NHS for the analysis of trends in obesity and overweight and underweight children.
I have to flag up to the Minister the concern that exists in my own constituency and across the country as a whole about the need for security of this data. We had quite a lot of discussion yesterday about obesity following the Secretary of State’s statement. I appreciate that this measure is only one aspect of the Government’s programme to tackle obesity. Again, if anyone wants to get to sleep tonight and is failing to do so, the current arrangements are described at length on the Department of Health’s website. Such reading is a guaranteed cure for insomnia. The Department of Health has issued a leaflet for parents called “Why your child’s weight matters”. It is probably an indication of the state of affairs that we have got to, that we have to say that.
There is guidance for PCTs and arrangements for measuring. Some of the regulations are highly specific about what machines are used and so on, which is important. If we are going to lump the data together, we need to ensure that data sets mean something. As I said, the guidance also sets out the legal basis for the current programme, the responsibilities of PCTs, the role of schools and local authorities, the schools covered, and lists of data collected and how they are stored and used. Separate guidance will also be issued for schools. That is a considerable burden on schools and PCTs.
There is concern about school nurses. The Royal College of Nursing—I declare an interest in that I am a member—supports the proposals that help school nurses to share information with parents on the well-being of their children. It sees it as a positive step that PCTs and the Government will work together to ensure that every child has access to a school nurse by making the adequate resources available. However, it is concerned that progress to achieve the Government’s target of one qualified school nurse in every secondary school and its cluster primary schools is slow, with evidence indicating that many school nursing teams have been adversely affected by the impact of NHS deficits, which I mentioned earlier.
The 2006 joint report by the National Audit Office, the Healthcare Commission and the Audit Commission entitled “Tackling Child Obesity—First Steps” indicated that head teachers reported that their ability to tackle health issues, such as obesity, was seriously inhibited by the lack of access to health professionals within schools and other educational settings. I am sure that I am not alone in saying that schools are increasingly worried about the burdens and responsibilities place on them for looking after an aspect of a child’s growth and development that they do not feel is their responsibility and that, in many cases, they do not feel well equipped to deal with. The presence of school nurses, therefore, will be crucial to the success of the programme.
The other point I want to raise relates to what we do with the information. In the light of some of the responses from strategic health authorities around the country, my concern is that it will be yet another box-ticking exercise. Their letters had an air suggesting that what mattered was that they reach the target for weighing and measuring children, and that was it—their job was done. But, of course, that is only a way of benchmarking health improvements put in place afterwards. What is crucial is the follow-on that we are able to provide and the resources.
I am sure that the Minister would be the first to accept that the weighing and measuring of children is important in public health. In any village in any developing country, the first thing that one sees is a sling on which babies are weighed. It is the first means of establishing, in those cases, the presence of malnutrition, and in general the state of young people’s health. That applies quite a long way up the age scale.
We ought to learn from the public health agendas of such developing countries, because we are in grave danger of losing out as a result of our more sophisticated approach to health care provision. We should issue the mother with a little booklet recalling over time all the weights and heights of her children—most of us of a slightly older generation will have experienced that. That would be a very powerful tool, because that information would be owned by the mother, which is more important than the broad statistical measurements in SHA or PCT measuring units. That is one way in which we could use such information. It would give the mother ownership of the health of her child.
My hon. Friend raises a very important point about ownership. I opened by talking about fatness and obesity, with one being something that happens to me and one being for which I am responsible. That endorses his point. The ownership by parents of their children’s health is extremely important. I must raise again the issue of hard-to-reach groups. Parents can withdraw their children from the programme, and I dare say that the child could withdraw themself. Even if a parent gives permission for their child to be weighed and measured, if the child on the day refuses, the school or school nurses could not insist otherwise. My concern is that the fat kids will withdraw.
Often, particularly with very obese children, there are huge issues about self-esteem. We have talked about anorexia and bulimia, and in relation to severe obesity there are many similar psychological overlays making children fat. This has a great deal to do with self-esteem. It is important that when we introduce the programme there is a safety net to pick up the children at that stage and to give them counselling, because there are other problems in their life. It gives us an opportunity to deal with those children and their psychological problems at a very early stage. Withdrawal from the programme is in itself an indicator that there are other problems.
Obviously, we would support anything that could be done to tackle the problems with obesity. If you will indulge me for a minute, Mr. Conway, I will return to the health in pregnancy grant and say that this issue starts with maternal health, foetal health and having enough midwives to support and encourage breastfeeding. In this day and age, women are not in hospital long enough to establish breastfeeding, and the problem starts from that point and goes right the way through. The work is quite resource-intensive; it costs quite a lot of money. However, if we really believe in joined-up government and want to make a difference, we have to see that investment up front in the areas that I have described will save—if we want to consider this purely in financial terms—a great deal of money in the long term, because we will prevent at an early stage all the diseases associated with being both underweight and overweight.
I think that the Minister finds these clause stand part debates slightly tedious, but the issue is important. He is shaking his head to show that he enjoys every minute of them, but he did not feel happy to respond to the points raised on the health in maternity grant. I hope that he will address some of these matters. The problem concerns us all, and the Government can make a difference if they apply themselves not to the headline figures or to the figures on children’s weight going down, but so that we see children at a more healthy weight, eating more healthily and living more healthy lifestyles to prevent the implications for the health service that we are storing up for the future.
May I put it on the record that there is nothing tedious at all about clause stand part debates? What I always try to avoid is repetition —particularly when I am given direction by the Chairman, who has asked specifically for brief contributions because many of the arguments have been explored and illustrated in debates on the amendments. I think that most members of the Committee find that tiresome and it is exactly what I was trying to avoid earlier. However, the hon. Lady has made some very important and new points and I will endeavour to respond to them to the best of my ability.
The hon. Lady asked first the most fundamental question: why is the legislation necessary? There are three reasons why we need to legislate. First, we need to give a legal basis to the existing programme. Secondly, we need to allow feedback to parents. She will be aware that at the moment people have to opt in to obtain the feedback, whereas this provision will mean that people have to opt out. We hope that it will mean that more parents receive the feedback. Thirdly, we need to legislate to allow the data to be used for performance management for local primary care trusts on their obesity strategies.
The hon. Lady has said, and I acknowledge, that this provision is a small part of our overall strategy against obesity, which was launched, and very well received, yesterday. I do not intend to broaden the debate out to that in general, because we are talking about a specific programme of weighing and measuring of children. She may not have mentioned it, but it is worth putting it on the record that another reason why we are legislating is that two Select Committees—the Health Committee and the Public Accounts Committee—specifically recommended that we did so.
As the hon. Lady will know, our target for 2006-07 is 80 per cent. coverage—that is the percentage of eligible children weighed and measured. We are confident that improvements to the programme will have resulted in much greater coverage and that there will be a vast improvement on the 48 per cent. participation that we achieved in the first year, 2005-06. We do not have those figures yet for 2006-07, but the hon. Lady might like to table a parliamentary question every few weeks and as soon as I can I will put them in the public domain. She is right to point out that the child would have the freedom to refuse. I do not think many people would suggest that we should force children, particularly given the self-esteem issues and the sensitivity that she rightly described, but we have developed a DVD and a flyer for children about the programme to help to reduce any concerns that they might have about participating.
PCTs will upload the data electronically to the national child management database, which will be developed and maintained by the Information Centre for Health and Social Care. The centre will not have access to child-identifiable data. When the data is uploaded to the database, it will be anonymised by removing or converting all identifiable data, including the name of the child; the postcode will be converted to lower super-output area, whatever that means; and the date of birth will be converted to age and month. Although the information centre will not have access to any patient-identifiable information, there are robust information security measures in place to ensure that the data is held and accessed securely.
Individual children’s results will not be shared with school staff or other pupils, and suppression and disclosure controls will be implemented when the data is set and publication released. That means that when the data is published, small numbers that could allow individual children to be identified will be suppressed. For example—someone must know what this means—at super-output area level, or even at PCT level, if numbers between one and five appears in any data cell, that number will be replaced by an X; so will any corresponding total relating to that number.