National Assembly for Wales

Bore da. Croeso, bawb. Welcome to the Health and Social Care Committee this morning. I move to item 1: we have no apologies this morning. If there are any declarations of interest, please do state them now. No.

In that case, I move to item 2. Item 2 is our inquiry—we're continuing our evidence-gathering session for our inquiry into the prevention of ill health and obesity. I would very much like to welcome Jeremy Miles, the Cabinet Secretary for Health and Social Care, this morning, to be with us. I would be very grateful if the officials could introduce themselves. Thank you.

Hello. I'm Jasmine Tompkins, I'm head of wider determinants of health.

Bore da. I'm Ed Wilson, I'm the deputy director for public health improvement.

Emily Finney, I head up the healthy and active team, Welsh Government.

Okay. Well, thank you for being with us, and, Cabinet Secretary, thank you for your paper ahead of the meeting this morning as well.

So, we've had a wide range of evidence provided to us, Cabinet Secretary. Obesity is a complex issue; we've established that. And, of course, responsibility and accountability is needed across many different sectors and organisations in this regard. So, with that in mind, are you content that each sector and organisation that can contribute to addressing obesity in Wales is given clear direction of their responsibilities?

Bore da, Cadeirydd. Well, it is absolutely the case that obesity is a very complex question, both in terms of its causes, but also, certainly, complex in terms of a policy response, and, as you say, a range of different interventions, and therefore, you know, responsibility for those interventions, are located in different places, understandably.

The challenge that we have in Wales is not a challenge that we face alone; I would say there's a global obesity crisis, really—the scale of it is absolutely enormous. And the reasons for people living with obesity are multifaceted. There are very often environmental or social contexts and causes to obesity, obviously influenced by environments like work and where we live, education; also personal experiences around trauma, for example, as well as, obviously, questions of personal agency as well. So, the strategy that we have of 'Healthy Weight: Healthy Wales', which is a 10-year strategy—as you know, there are two-year delivery plans for that strategy—seeks to grapple, really, with the breadth of that and the complexity of that. So, our next two-year plan is about to be published later in the spring and I think that has a very clear direction, actually, to the various agencies, the various actors, if you like, in this space—so, local health boards, local authorities—but also expectations of food manufacturers, retailers, sports organisations, travel providers. You know, I think when you see that published, you'll see a clear sense of where we think responsibilities lie in the system and a way of co-ordinating and marshalling that in a collective effort.

Thank you for that, Cabinet Secretary. And you referred in your answer to the delivery plans and those two-year timescales. So, in terms of the 2022-24 delivery plan, are those objectives being met, in your view? And the second question is: you also referred to the next plan being announced in the spring—it's good to know that—what will the focus of that plan be, perhaps, that is different to the current plan?

Well, in terms of where we are as against the existing plan, I would say there have been good areas of progress. Clearly, the level of the challenge is very significant for Governments everywhere. So, I think, in terms of weight management systems, we've seen an increase in both capacity and probably in terms of improved quality of that provision as well. We obviously committed to expanding specialist services by 2030. We've drawn, I think, effectively on international evidence of what works in other countries. I should say there is very limited evidence, internationally, of what is effective—that's the truth of it—and there are no countries that have been able to actually turn round the level of obesity. There is good evidence, in relation to childhood obesity in particular, in parts of the world. Anyway, we've drawn on some of that international best practice, and what that tells us is about regional teams with a whole-system approach—that's the solution to the challenge. So, we have those teams in place, they've been able to identify areas of priority for us to change. So, I think, in terms of working with young people, with food outlets, there's good evidence of that happening. And obviously as well, as the committee's well aware, we've introduced legislation in this space as well. So, I think there are good examples of progress against the current strategy.

In terms of your second question, 'What's the focus, if you like, of the new delivery plan?', drawing very specifically on that international experience, what we know is that the interventions, which are available to any Government, are most effective when you're talking about childhood overweight and obesity. We also know that, if you're able to improve levels of being overweight and reduce the level of obesity in children and young people, that clearly is likely to have long-term benefits. So, what you will see in the new strategy is more of an emphasis on tackling overweight and obesity in children and young people. Of all the things I've discovered in this role, since I took it on in September, I think probably the thing I find most terrifying is the number of children aged five who are overweight or obese, which I think is running at about 27 per cent. Now, that is a huge problem for those individuals, but it's clearly a huge problem for the system as well, in all its facets, if we aren't able to tackle that.

So, I think what you're suggesting is that the focus of the next plan will be more aimed at tackling obesity levels in younger age groups.

Yes.

So, I've understood that. You've talked about good progress being made on the current plan. But in terms of the priorities within the existing plan, the 2022-24 plan, are there any priorities that have not been met, or have not been met as well as you would have liked, perhaps, I should say?

Well, I guess the challenge, really, is the question of the overall scale of the challenge, isn't it? I've pointed out areas where we have made progress, but, clearly, there's much more to do, isn't there, in a general sense. So, there's a level of ambition, I think, in the new delivery plan, which I think helps us make that more rapid progress in relation to young people. We've drawn on evidence, in particular, I think, from Amsterdam, where we've seen good progress there. So, it's baking in that good practice from elsewhere as well.

I've got a few more questions, but, James, did you want to come in on that point?

On the new delivery plan, how cross-Government is that? Because if you're going to address obesity, it doesn't all sit with the health directorate, does it? It sits right away across all different Government departments. I'm just interested how other Government departments are fed into the new strategy, because it's key, if you're going to address this problem, that there has to be a whole-Government approach, doesn't there?

Yes, absolutely, there has to be, and it does touch, practically, on every portfolio, in some way. So, there is very good cross-Government working, as there has been for the existing plan, actually. So, the timeline at the moment is that there's going to be a Cabinet discussion, which brings together all the work that's under way, at an official level, in relation to the strategy, and then once that has been discussed at Cabinet, the plan will be published. So, that stage, if you like, is baked into the publication of the plans. There will be cross-Government approval of the policy. It won't simply be a health policy, for the very reason that you set out.

Could I have one more quick—? Just following on from that, then, will there be a cross-Cabinet committee looking at this as well to bring it all together to make sure the plan is actually delivered? Will you be chairing any groups around that to make sure that happens, just so that there's a bit of oversight of what's going on?

Whether there are committees is a matter for the First Minister, obviously, in terms of Cabinet composition. But there will, absolutely, be a cross-Government governance mechanism, if you like, to make sure that all the priorities in the plan, which are informed by departments across the Government, are being pursued in the way that the plan sets out.

Okay. Diolch. 

How is the implementation of the plan measured? I’m thinking of the current plan. I’m thinking about transparency, so that all can see that the measures are being either met or not met, and there’s a degree of transparency. And are there any changes in the next plan that you intend to make to make it more easy to be more transparent, and more easy to be measured?

Yes, a couple of things on that, Chair, I think. So, in terms of the governance of the plan overall, we’ve had some feedback from the national implementation board that we could make some adjustments to that, to make it maybe a little bit more nimble, probably, in reality. So, we’ll be baking that into the new plan.

As you said in your first question, the range of players in this space is, obviously, a broad range, so making sure that everyone has an opportunity to contribute in that way is, obviously, critical. So, there will be some refreshed governance arrangements in the new delivery plan when that’s published. And on the—

Is there anything you can say about them now at all?

Well, I think it's what I’ve just said, which is to try and make them a bit more practically focused maybe, and able to respond to progress, and lack of progress, in different areas more rapidly.

Okay. 

But we’ll share that with you. And just on the point you were making specifically around measurement, we’ve asked Public Health Wales to develop a suite of further performance measures for us to use as a tool to measure performance against the plan. So, that will be part of the new regime as well.

Okay. Thank you. Mabon, you wanted to come in. 

I may ask Ed to come in on the bulk of that, because the plan, in terms of its day-by-day execution, obviously, predates my time as Minister, generally. 

I think the one area that I have identified as needing more focus is shifting the bias to early years. I think that’s where we need to make more progress. And I’m actually optimistic about that, because there’s a range of Government policies in this space already—so, food in schools, through to active travel and rolling out sport. So, the tools and the levers are there. Having a kind of joined-up approach to how that can be used to benefit children and young people, I think, is where there’s room for us to do more. But, in terms of the broader point around performance under the previous plan, Ed.

Yes, thank you, Cabinet Secretary. So, in terms of the current performance measures, we use national survey data around the levels of obesity, and also the child measurement programme. As the Cabinet Secretary said, we think there are areas for potential progress, particularly with children and young people. The most recent child measurement data does show a statistically significant drop in childhood obesity, compared to the pre-pandemic report. So, progress has been made, and there is potential for us to do more. We’ve outlined some of the areas of success. There are other areas such as working very closely with Transport for Wales, in terms of their onboard catering, and also advertising a Transport for Wales-owned premises.

And I think one of the areas that we also, perhaps, would like to make some more progress on, which will be part of the delivery plan, is working with the food industry. So, we’ve seen success where we’ve had conversations both on a voluntary and on a regulatory basis with the food industry to improve the nutritional content of food, both in terms of reducing calories, salt and sugar—the sugar levy is a good example of a regulatory implement working at a UK Government level—and the work that we are undertaking with Welsh businesses to look at how we can support them to reformulate some of their products. So, there’s hope for the next delivery plan to make some more progress in those areas.

Thank you. John. 

Only very briefly, what's the extent of the reduction, then, in obesity in children that you mentioned?

I can write to you on those specific numbers. It’s a couple of percentage points down in terms of overweight and in terms of obesity. There was an increase in childhood obesity and overweight during the pandemic, which I think is reflected in the adult population as well. But these are compared to the last pre-COVID figures. So, there has been a reduction, because I think, as we came out of the pandemic, there were changes to people’s diets. The statistical significance of the latest data is compared to pre pandemic. I don't know if, Emily, you've got the figures, or we can write to the committee.

Yes, I've got the figures, if that would be helpful. So, in 2018-19, the figures were 14.4 per cent overweight and 12.6 per cent obese. In 2022-23, it was 13.4 overweight and 11.4 obese.

What ages?

Sorry?

What ages are we referring to there?

That's for children pre school, so age five.

Pre school.

Yes.

[Inaudible.]

I'm sorry, I can't hear you.

The last figure, was it in 2023?

Yes, 2022-23.

In 2022-23. Thank you.

I appreciate you writing with those figures, but it strikes me—. Those figures that you've mentioned, are they already in the public domain or not, and if they're not, is there a reason why they're not, because that will help, I suppose, to drive transparency as well?

Public Health Wales will publish the child measurement programme data as it is collated, so it will be available on Public Health Wales's website. Yes, it is publicly available.

Okay, that's helpful. I suppose the final question, before we move on—. What we have heard is that there are different areas that can contribute to a person's weight and any plan has got to get the balance right between Government intervention and personal responsibility. Is there anything you can say on that in terms of how that comes into your next plan in terms of the balance between the two?

Yes, there is a balance between the two. I think there is a risk, isn't there, if you focus on what we would probably regard as behavioural interventions, which are really focused around personal choice and agency, then you miss some of the context that is critical to people's ability to manage their weight healthily. You could, I think, quite easily make the argument that we live in an obesogenic society. So, I think a lot of the focus in the plan is around how we can tackle some of those environmental or structural challenges that make it more likely that individuals are overweight or obese. There is, obviously, a correlation with deprivation, but that's really part of the rationale, in response to James's question earlier, why a cross-Government response is needed, because some of it is, obviously, in the health space, but there are elements in education, and there's a planning dimension to this. Clearly, there's a transport dimension. I think you have to see that whole range of context as well as questions of personal responsibility or choice, if I can put it like that. But the other context, which is, I think, a very real context, is when people hear Governments talk about the need for changing behaviour, that's quite a complex message to convey in a way that is well received and, I would argue, increasingly complex for a range of reasons. And so, I think our hope is, and we have some expectation, that where we talk about it in the context particularly of children and young people, the audience for that sort of health message is generally a bit more open, because there's a wide understanding and a shared commitment to the health of children, isn't there. That's also part of the thinking behind the new delivery plan focus as well.

Okay. Thank you. John Griffiths.

Diolch, Cadeirydd. I just wanted to touch, Cabinet Secretary, on some of the issues around stigma and mental health. We've heard from psychologists who work in weight management services in Wales that weight-related stigma is actually an issue for the majority of the patients that they see. So, I'd be interested in how you think 'Healthy Weight: Healthy Wales' tackles that stigma problem, and the discrimination that also exists. Are we really delivering health services that are person centred and empathetic, and how do we evaluate that?

Yes. Well, I think, as behavioural messages are, questions of stigma are complex and deep rooted in society, aren't they, and we will all understand the level of stigma that can go with being overweight or obese, and it presents a burden, doesn't it, for those individuals. So, there are complex things at play there. In terms of how the system responds to that and how the strategy responds to that, there is a commitment in the strategy to provide specialist weight management services, as I mentioned earlier, by 2030, and part of the specification for providing those services relates to the minimum service requirement, if you like, in the specification, and they set out how services should be designed and delivered in a way that recognises and responds to, maybe, adverse experiences, trauma, sometimes mental health issues, which can both be the cause of and create more challenges, if you like, for individuals with overweight or obesity. And so, as part of that, health professionals are supported to recognise when there needs to be psychological intervention—so, when the services need to engage a psychologist to work with the individuals, and that can be around mental health issues, disordered eating and eating disorders, questions of trauma and how they relate to weight loss.

Is there enough psychological support at all levels of care, do you think? Is there enough input from psychologists? 

I think that the need for input depends on the level of intervention, doesn't it? So, as you would expect, as you move up the levels of clinical intervention, there is easier access, if I can put it like that, to psychological support. We've, I think, put about £3 million into the system specifically in order to support health boards to develop and deliver services that encompass the kind of support I've just been talking about. We've set an objective to health boards to expand levels 2 and 3, which are the higher levels of intervention—to expand that provision by 10 per cent. And I think they're all on track to do that. And, obviously, those are the areas where you'd expect to see more psychological support available. 

Okay. Thank you for that. I'd be interested in your view on whether there is enough integration—enough joining up, I guess—between weight management services and other services, such as those for mental health and eating disorders, for example. Is that really joined up, and how does that relate to waiting times?

I think there's always more that can be done to make sure that services aren't provided in isolation and aren't siloed. You'll know that we're about to publish our mental health strategy in the next few weeks, which I think will give more context to that. But, as I was touching on earlier, questions of self-esteem, self-efficacy, resilience are often very embedded in the experience of people looking for support with their weight. So, having that joined-up and lifelong approach is important as well. So, the new mental health strategy is an all-age strategy, which I think is really important in the context of managing overweight and obesity. And what we particularly know, and the children's weight management pathway spells this out specifically, is that particularly where you're trying to support children and young people with weight management—the point you were making earlier about stigma—doing that in a way that recognises the risk of stigma and minimises the potential to restigmatise is absolutely critical if what you want to do is change lifelong behaviours.

Yes. Okay. Thanks for that. 

James.

You mentioned the all-Wales weight management pathway, and tier 3 of that is actually where people come in with that psychological help there. I'm just interested to hear from you, Cabinet Secretary, what are the waiting list times for people who are actually waiting for that psychological support to deal with weight management?

I actually don't have that information, but I can provide it to you if we have it. 

Yes, it would be quite useful to have that because, as I said, people who wait longer actually are struggling because of adverse effects. So, it would be useful to have that. Thank you.

Thank you. Mabon ap Gwynfor. 

John Griffiths.

Diolch, Cadeirydd. Cabinet Secretary, in terms of the overall effort to tackle obesity, the provision of services and treatment, what would you say is the role of weight-loss medication in that overall picture?

Well, it's had a lot of profile, hasn't it, recently? And the expansion of the availability of weight-loss drugs has been pretty exponential in the last year or so, I would say. So, the general point, if I can make this point first, is: tempting though it appears, there is no treatment-based approach for any health service anywhere in the world that is going to be able to manage the scale of the obesity crisis that we are facing. So, that's why we've been talking so much about prevention. Whatever your health service, wherever in the world, it's not a feature of the NHS, it's not a feature of the NHS in Wales, it's just a feature of the scale. Focusing on treatment, when people are already overweight or obese, simply can never be sufficient to manage the scale of the challenge. So, just to provide that context to start with. But, obviously, that's at a population level, for particular individuals, maybe especially if they face things like hypertension or type 2 diabetes, then clearly there can be a role for weight-loss medication in supporting them to manage their weight healthily.

So, I would say that there is a role for them, however, the focus must not be taken away from the prevention aspect, which is absolutely where the longer term solution will lie. We already allow prescription weight-loss medicines in Wales as part of the weight-management services that we have, but in a way that ensures that they are also accompanied by support for a healthy diet and physical activity. That wraparound provision is absolutely, absolutely essential, really.

Yes, I think that weight-loss medication tends to be taken for a maximum of two years, doesn't it? And sometimes when it ends, people than re-gain weight, and that makes you wonder to what extent underlying causes have been addressed, and also what support is put in place alongside the medication. So, I guess it's a question of whether the use of those medicines provides value for money over the longer term.

So, most of the weight-loss drugs, I think, are recommended for two years, but I think I'm right in saying that some of the more recent ones, which are currently going through the NICE process, may not be limited to two years; that's my understanding. So, that, in a sense, changes the discussion a little bit, and there will be further drugs that come, obviously, and so, you would expect, I think, for that not to be limited in that way.

But the basic question was about, 'Does it provide value for money?' So, if the question is, 'If we provided more weight-loss drugs, could we, as it were, save the costs of some of the other clinical interventions that the NHS does to support people with diabetes, and is there a value-for-money relationships there?', my understanding is that that is not the case. So, it's not a sensible assumption to say, 'Well, if we provided weight-loss drugs more broadly, we would save more money in the NHS.' The economics of it don't work out like that, and, in fact, I suppose you could imagine when there are generic versions of these drugs available, then that calculation might, to some extent, change, but we are talking a very, very long way into the future for that, in any event.

Okay, thank you.

James, do you want to come in?

Yes. The NICE guidelines around the implementation of these drugs is actually the person-centred approach and doing everything first. We do know, across Wales, that there are some higher prevalence of obesity rates. In Powys, it's about 54 per cent; in Blaenau Gwent it's up around 74 per cent, or 75 per cent. I'm just interested in how Welsh Government are making sure that GPs and health boards are making sure there's a consistent approach to the administering of weight-loss drugs across the country, to make sure that in some areas they're not being overprescribed to try and address a problem, whereas in some areas they may not be being prescribed at all, and making sure there's some consistency across the country with that.

I think that's a very good question, and I think we're in the early stages of understanding what that looks like, but it is absolutely a key risk, if I could put it in those terms, because, obviously, these drugs are available for other provision—

Yes, in Boots.

Well, they're also available through the NHS for other conditions, so there's a question around that. So, that's part of how we will approach responding to—. There are draft guidelines from NICE at the moment, when those are final, we'll need to look at what that means in practice.

So, you may know that the NHS in England has asked for a 12-year implementation period. I think that just recognises the scale of the services that need to be there to be able to support people healthily on weight-loss drugs, the wraparound services, the diet support, the physical activity support. We only provide them currently through, effectively, a secondary pathway in a weight-loss management service. So, we would need to look, in light of the new guidance, at how that, over time, might be rolled out beyond that. But there are lots of very open questions in that space at this point in time, I think.

Following up on that, if I can, Cadeirydd, actually, because these drugs tend to be available in a myriad of places. I could go to Boots, or other pharmacies are available, across the country, and they can prescribe to you from there. These drugs have some quite nasty side effects, which a lot of people aren't quite aware of either, and I'm just wondering what conversations you're having with colleagues in other parts of the United Kingdom around these sorts of drugs, around the more controlled element of them. From a personal perspective, I'm not sure a drug like this, with the side effects associated with it, should be as readily available as it is, perhaps, now, and I was just interested in what conversations you're having across the border around that.

Those are, of course, judgments that NICE take into account before they provide the authorisations that they provide. So, that exercise will have been undertaken in the authorisation and licensing process, as you obviously appreciate. There is a live four-nations discussion around weight-loss drugs generally, and I myself had a round-table a few weeks ago to explore some of the dimensions as they would apply in the context of the NHS in Wales.

I think the fundamental point in this space, just to be clear, is that we don't yet know the long-term trajectory, so that's the most obvious challenge at the moment. Clearly, as each year passes, that becomes less of a challenge, but no-one can yet say, really, what the long-term benefits or downsides can be. I think it's pretty obvious that where it helps change behaviour and where those behaviours are positive and continue, then that clearly is a long-term benefit, but we're still in quite an emerging understanding across the world, really, at the moment.

That's fine. Thank you.

Thank you. Joyce Watson.

Good morning. I want to move on to breastfeeding. We're talking about the very start of life for the newborn and having healthy options right at the beginning. There is a five-year breastfeeding action plan, a Welsh Government one, and the hope is that it will sustain breastfeeding in the communities, and I know, at the moment, it's being reviewed. So, what is that looking like?

Well, in terms of the performance of the existing plan—. As you rightly say, there's a new plan being designed; Public Health Wales are reviewing the existing plan with a view to an infant feeding plan following from that. The benefits of breastfeeding are clear, so we won't need to repeat those here today, but the levels of new parents choosing to breastfeed at the point when they're new parents is actually at an all-time high. So, that's two thirds of new parents, which is good. Obviously, we want it to be higher, but that is positive. What then happens is, as you get to the end of the six-month period, when the World Health Organization says that, ideally, that's an exclusive period of breastfeeding, that figure drops down to about 29 per cent, which is too low. So, we've seen progress overall in lifting the numbers, but that does tail off towards the end of that six-month period, and, obviously, we need to make sure that those figures remain as high as they are at the start. So, that, I suppose, is my assessment of where we are today. There has been progress, but, clearly, there's more to do in that latter period.

There'll be a multitude of reasons for that six months, and a lot of it might be going back to work, and the advice that's given, then, on feeding that infant post breastfeeding is critical. But the healthcare workers who go out and visit parents are also critical in this space, particularly when families aren't necessarily living in the same area, for example, whereas they used to. So, how is that being joined up?

Do you mean in terms of staffing?

Yes. In terms of making sure that the advice that's given initially in hospital is followed through by a health visitor, especially since some only stay in hospital for a matter of hours now.

Yes. Well, that's part of what the plan seeks to do, to deliver that consistent approach so the advice is consistent, but also recognising, as you rightly say, that, as people go back to work, then it becomes often more challenging, around workplace settings and social norms, if you like. So, the plan seeks to grapple with a number of those areas. What we are hoping to develop further, if I can put it in those terms, is, when the infant feeding plan is published, there'll be an outcomes framework around that that will measure some of the inputs—some of them you've touched on in your question—and that will take into account what we've learnt from the breastfeeding plan over the last five years and seek to improve on it.

And of course, the workplace is critical here in providing space for mothers who have returned to work, probably out of necessity, to feed their children—literally. So, is that feeding into this as well?

Yes, absolutely. So, the work that Public Health Wales is doing is taking all of these factors into account in developing that infant feeding plan.

I'm moving on now to the child measurement programme for Wales, which measures the height and the weight of four and five-year-olds, but we've had suggestions that it should also do the same for 10 and 11-year-olds. So, does the evidence support extending the programme to older children?

Well, there's a review under way of this at the moment, both from a merits point of view—what are the pros and cons, what do we learn from that—on the one hand, but also the resource implications of it as well. There's obviously a resource implication. So, again, Public Health Wales is leading on that review for us, and what they're looking at is whether a second measurement point in the last year of primary school meets that objective. So, we don't know the answer to that yet, but that work is under way.

If you measure the height and weight of a child and you can see that they're overweight—not obese, but heading to being overweight—is there support put in place then to give advice, rather than fear?

Yes. A lot of the level 1 support is very much along those lines. So, whether it's some of the interventions we've talked about already—. But we've also got the Every Child Wales resource, which is a digital resource, available to parents, but also there is signposting to other services at level 1 as well. That is very much about advice and support and self-management, effectively.

I'm going to go on now to the PIPYN pilot programme. It focuses on the inequalities that have been mentioned here today that lead to obesity or overweight. It has been rolled out in Anglesey, Cardiff and Merthyr because of the high levels of childhood obesity. Could you give us some information on that pilot programme, particularly the outcomes and whether there is any possibility of expanding that to other areas?

Yes. So, the pilot is in three different areas, so that we get a range of experience. It's working with families with children in the three to seven age range, and it's really about supporting families in their awareness of healthy food and healthy cooking in the home—and there has been some success, we think, anecdotally at least, at this stage, from that—but also working with other local players, if I can use that term—so, local authorities but also childcare providers and a range of others—about how families can be, as it were, more exposed to healthy food options and healthy ways to eat. So, our understanding to date—it's being evaluated formally at the moment, so these aren't conclusions at this stage, but they're observations, I suppose, from the pilots—is that there has been a high level of engagement, and, actually, that's quite challenging sometimes for families with young children, for lots of reasons, but one of them was the point I was making earlier, about building a relationship of trust. There seems to have been some success in the work that has been going on to date, but there'll be a proper evaluation of that and then we'll see how that might be taken forward, depending on the outcomes.

I think one of the big issues of overweight and obesity starts very early on, when children are rewarded with sweet items for good behaviour, so there's a connection made straight away that that is a nice experience, and it's a way of rewarding yourself for the rest of your life, quite frankly. Is there any work or evidence that is helping to inform perhaps new parents, even, to give those rewards in a different way? 

Yes, so, some of that—I might ask one of my colleagues to come in, but—some of that is in the digital resources that I mentioned earlier, which support women in pregnancy, but also new parents in terms of healthy weight for their children. But the regulations, for example, that we've brought in, that the Senedd voted on last week, around the placement of food in supermarkets, are really seeking to tackle that pester power as you're waiting to pay for your groceries. When you're surrounded by Mars bars and crisps—other unhealthy foodstuffs are available—[Laughter.]—then we know that people are going to end up buying them, aren't they, in that context. So, part of that is around supporting parents to help their children with weight. But anything further for colleagues to add?

Yes, thank you, Cabinet Secretary. It's societal, isn't it? It's ingrained—as adults, we also treat ourselves with alcohol, don't we, in the same way as we treat ourselves with treat foods. It's something that you grow up with, as you do when you're younger. The '10 steps to a healthier weight' campaign, launched as part of Every Child Wales by Public Health Wales, supports pregnant women and parents of children up to the age of four, and there's mandatory training for all professionals who work with children up to that age around health and nutrition. But it's absolutely something that we'll consider as part of the next delivery plan.

Okay.

Thank you. Mabon ap Gwynfor.

James.

Really quickly, Cabinet Secretary, I’m just interested here—. We've been talking a lot about families, but, actually, the health providers in some of the more deprived areas of Wales see a lot more of this on a day-to-day basis than perhaps other areas of Wales that haven’t got obesity rates so high. I’m just interested about the inverse care law, that we should put more money, actually, in those areas where there's more deprivation, into health services. I'm just interested in how the Government is investing in more primary care in those more deprived areas, to make sure they can address these deprivation issues, because the issues, as I said earlier, in certain parts of Wales are a lot more different to the more affluent parts of Wales.

I would just make the cautionary note that there's a problem of obesity in all parts of Wales—I just wanted that to be clear. But from the point of view of how we allocate primary funding to reflect deprivation, that is already part of the funding formula, although you will be aware there is a live debate about whether that goes far enough, and, if not, how do we then take it further.

The Deep End practices—we fund the Deep End project in Wales—are a group of GP practices serving disadvantaged communities, as you know, and they would make the argument that there needs to be a rebalancing of what's known as the Carr-Hill formula, which is the mechanism by which funding is allocated to GP practices.

Our view as a Government—but it is a live discussion—is that that may not be the best way of making sure that those practices get the support that they need, and that there are other ways of doing it, which would be outside the formula, about providing the kinds of additional services that you're talking about to support disadvantaged communities. And we already do that, but there's obviously a discussion about whether there's more that can be done. I absolutely recognise the pernicious ongoing existence of the inverse care law, and it is a real challenge.

I wasn't trying to say there was no obesity in certain parts of Wales, Cabinet Secretary; it's more prevalent in some areas than others.

Thank you. Lesley Griffiths.

Thanks very much, Chair. What's the Welsh Government's current view of having a national food strategy?

You'll be aware of the 'Food Matters' position paper, I suppose you'd call it, which we've published on an interim basis. There's a community food strategy, which has been developed; it's been discussed at Cabinet on a cross-Government basis. Obviously, that encourages healthy food production, grass-roots level initiatives and how we can embed considerations of food across all policy areas—so, policy planning, but service delivery as well. Clearly, I have an interest, as health Minister, the education Minister has an interest, and the agriculture Minister has an interest. I can't remember when that's going to be published, but it's been discussed at Cabinet recently, so it'll be brought forward soon.

I think, actually, that every Cabinet Secretary and every Minister has an interest in food policy of some type. So, as health Cabinet Secretary, are you content—we've got these very disperse food policies right across the Welsh Government—that not having a national food strategy will ensure that people aren't working in silos?

I think, when you see the community food strategy, it does touch on all the areas of Government. I've had input into Government; other parts of Government have as well. I agree with you, that's absolutely essential.

In terms of the supply chains for food in Wales—I'm conscious that I'm speaking to a former food Minister, so slightly diffident about wading into this area—as you will obviously know, those are very intertwined with UK-wide supply chains. So, we are working closely with the UK Government on its food strategy, and I think that work is going quite well.

That's really good to hear, because, obviously, the UK Government, in the Dimbleby report—. I think the thing that came out to me, when I read the Dimbleby report, was that we need to have bold action if we are going to tackle obesity. It's really good to hear that.

You talked about discussions that you've had with other colleagues in Cabinet. I was just wondering if you'd had discussions with Rebecca Evans, for instance, around planning, and making sure—you talked about pester power before, in an answer to Joyce—that, outside our schools, outside colleges, we don't have an increased number of fast food outlets, for instance, shops that sell very unhealthy foods. So, I was just wondering what discussions you've had with Rebecca in relation to that.

We have had discussions, and I think you're absolutely right to say—. It goes back to the general theme we had earlier of how you can design out some of challenges that people otherwise would face, and the prevalence of fast food, hot food takeaway stores on our high streets is, I think, a really significant challenge. As you might know, Wrexham council—in fact, the only council in Wales—has been doing good work in changing its planning policy around the location of new fast-food outlets within 400m of a school. I don't think we have any evidence of outcomes from that yet, but I think the WLGA have been interested in that, and clearly we are working with local government to see whether that can be picked up by other councils, bluntly.

Public Health Wales has done a piece of work—it's public, it has been published—which shows the density of fast-food restaurants in different local authorities in Wales. We have some evidence that there is a link between the density of fast-food outlets near schools and the BMI of pupils in those schools, which is very problematic. There is good evidence, I think, in all of Wales, even where councils haven't made the decision to change their planning guidance locally in the way that Wrexham has, that health boards are working much more closely with local planners around some of these questions, and we see pockets of success, if I can put it like that.

I suppose the challenge for us is to make sure there's a consistent national approach that underpins that. It's probably quite challenging for councils in some areas otherwise, because there are competing tensions, aren't there, between the health agenda on the one hand and the kind of vibrant high street agenda on the other. So these are, I guess, difficult things to weigh up.

What about discussions with the Cabinet Secretary for Education around healthy options in school meals, but also skills? When I was in school a long time ago, we had domestic science. I was taught to cook from scratch. When my daughters, 20 years later, had cookery programmes, they took in ready-made pastry to roll out. They weren't taught how to do pastry. I don't know whether you did anything when you were Cabinet Secretary for Education, or what discussions you've had.

But also school meals; obviously, as a Government you have put significant funding into ensuring children are fed in schools. But again, looking at school meals 20 years ago, I never saw a fresh piece of vegetable, when I was a school governor, in the kitchen. There was no potato peeler in sight. Everything was frozen, everything was deep-fat fried. I wonder what discussions you've had with the Cabinet Secretary for Education—I know you did work around this area, too—to make sure that the nutrition and food, and not having overconsumption of food—. What's being done in our schools to make sure that happens?

This is a very interesting area and I think it's an area of huge potential. I do think that the new curriculum on the one hand, which has requirements around teaching children about healthy eating and the provenance of food, and connecting food to environmental questions, all of that on the one hand, and at the same time the introduction of the universal primary free school meals policy—I think the fact that those two things are happening at the same time is a huge opportunity for us. I think the next opportunity is how you can take that one step further and make sure that local produce ends up on plates in the schools. There's a huge potential for that, which is untapped, I think, at this point. I've been working closely with the education Minister on this, and as you say, I was very interested in this when I was education Minister. Lynne is about to consult on new healthy eating in schools regulations, which touches on all the points that you raised in your question. I think that's coming up in the next few months, and that will obviously provide an opportunity to look both at the balance of nutrition, but also portion sizes and all those other things that you were talking about.

That's really good to hear, thanks. Can I just go back to the food regulations that were passed in the Chamber last week?

Yes, but Lesley, do you mind—? There are a couple of people who want to come in, and then before you move on to food regs, I'll come back to you. Joyce, you had a question.

I want to go back to the planning. That’s the point where I was trying to come in. When planners, local authorities, are trying to prevent some of the multinationals with a lot of weight behind them locating, they become very risk averse, simply because, if they refuse it, they go to appeal, and I don't know that any of them have won those appeals, and they're hugely costly. So they have to balance what they want to do with the cost to the local authority—in other words, the taxpayer. What I'd be really interested to know—and you've mentioned Wrexham changing their policy—is at what stage can a local authority intervene in their own policies, and what weight does it have for them in exercising what they want to do, rather than facing the challenge of the consequence of doing it. 

We've reached the limits of my understanding of planning law in my contribution already, but the broad point—I might bring Emily in on this in a second—is that's why having, as we do, national planning guidance that is specific on this, and local planning guidance, as some local authorities have, is obviously critical, because complying with your own guidance is where these challenges start, isn't it? That's why I would be keen to see more local authorities adopting that approach in their own guidance. But I don't know if you're able to help on this. 

Only if it's brief. I'm so sorry, Emily, but we're just a bit stuck for time. We can have some written correspondence if that's more helpful, unless it's a quick response. 

Very briefly, there's lots of research going on in England where some of these decisions have been challenged more than in Wales. It's very much about the data and evidence at local authority level that can support why those interventions are made. And when they are challenged, that evidence can then support that. So, it lies at that data and evidence provision element. 

Okay, thank you. 

Thank you, Emily. Mabon, you had a question as well. 

There is some evidence that there is a correlation there. I think it's one of those issues that's very much emerging at the moment. It's very much around schoolchildren are very much more likely to go to a fast food premise if it's on their route to and from school, but also the wider food environment that children are exposed to has a role to play as well. So, there's some evidence in this area, but it's very much emerging in terms of what that's telling us. 

Okay, thank you. Lesley. 

Thank you. Going back to the food regulations, I was very pleased to see them passed last week, because I think, going back to what we were saying about not encouraging overconsumption of food, et cetera, those regulations will ensure that unhealthy foods are restricted in the promotion by companies. Is that the effect that you're hoping the regulations will have? As the Cabinet Secretary for health, what other impact do you think this might have on the levels of obesity?  

The impact that we want to see and do expect to see is a reduction in the level of premature mortality. That's what it relates to, in the individual's life. We think there'll be a significant positive impact in that space. As the Minister responsible for the health service as well, there will therefore also be positive impacts on the capacity of the health service to respond to this health challenge. But I think more broadly even than that, we think the broader economic effect, if you like, in terms of people living healthier lives longer, is many, many billions of pounds—£6 billion or £7 billion. So, I think in all sorts of different ways, most importantly, obviously, from the point of view of the individual's health, there are system-wide benefits as well that we foresee. 

Again, not your portfolio, but have the retailers asked for support? 

Yes. To be fair, there have been very good discussions with retailers throughout, so I think the level of dialogue has been very positive and that's obviously helped us shape what I think is a set of regulations that are proportionate, recognise the particular pressures that very small premises might face, or very small retailers might face, or those that sell mainly sweets and crisps. There are obvious practical challenges there, aren't there? So, they've all been, I think, well navigated. 

There's comprehensive supporting guidance that we will publish shortly now that the regulations have been passed, and there's also training with retailers about what this means in practice. I think we've already had some workshops, but there'll be guidance and training over the course of the next year, before the regulations come in next year.

The UK Government are looking at similar regulations in relation to advertising, which I actually think will have more impact on young people. So, as a Government, are you working with the UK Government in relation to that, or are you thinking about bringing forward any other types of regulations?

We are working with the UK Government. So, the new UK Government has taken steps, as you will know, to bring in some limitations on advertising. It's very disappointing that that didn't come in earlier, under the previous Government, frankly, because I do agree with you—the impact of a restriction on advertising is likely to be even more significant, for obvious reasons. So, that work is already happening. In terms of what next, I mentioned in passing to Mabon ap Gwynfor earlier that we're looking at a mix of options, really—so, what voluntary actions we could take, building on the regulatory basis that we've now got in place with retailers about introducing healthier options. I happened to be in London the weekend before we voted on the regulations, and I was walking up to the till and I quite fancied a bit of chocolate, but I didn't buy it because there wasn't any there, and I ended up buying nuts, and I thought that's the kind of—it's anecdotal, isn't it—that's the sort of change that you want to encourage in the system, isn't it. So, it's that at scale, really. There will be other things. Obviously, we consulted on some things in 2022, so we will keep that under review, and there will be some things in the new strategy on this as well.

Diolch.

Thank you. James, if you want to cover both your subject areas, and then I'll come to Joyce for the subject area she wants to cover. James.

We talked about it a little bit earlier, about how the Government can perhaps intervene with food processors on actually making options more healthy and actually making menus more healthy. I'm just interested in what work the Government is doing in this space at the minute and what interventions the Government is making in the food environment. I know it probably sits outside of your portfolio a little bit, but, in terms of interest, if you know a little bit about that.

In which context specifically do you mean? Do you mean—

In terms of driving out sugar and salts and everything out of food, and improving recipes, and the rest of it.

Well, where we have more direct levers, if you like, for example, in the public sector, clearly, in hospitals and in schools would be two good examples. There's a piece of work already under way in relation to hospital food, which is being led by the chief nursing officer, who's responsible for that policy area. I think we'll be able to say some more about that over the coming months. I mentioned the work that's about to go out to consultation in relation to healthy food in schools. But alongside that, there is an existing architecture, if you like, around delivering healthy menus. So, that's either at a local authority level, where that is the model for delivering school food in that particular authority, or, sometimes, it's at a school level, depending on how they design it. So, the responsibility for complying with the regulations and designing a menu that meets those objectives lies at either of those two levels, depending on how they deliver school food. And there's, alongside that, a WLGA resourced service, if I can put it like that, which helps local authorities with this work, gives them training about how they can comply with the regulations. So, obviously, that would continue under the new regime.

Across the public sector, obviously, procurement—. You touched a little bit on it within the health sphere. That's within your portfolio area. I know we just briefly touched on it. What sort of work are you doing through the joint commissioning committee and the rest of it to actually make sure we have more healthy food within our hospital settings? That's not just for patients as well, but actually giving staff options to have a healthier meal in work.

So, that work has been under way as part of the review that I just touched on in terms of hospital food. I think, on procurement generally, we've been looking for ways to maximise that opportunity for locally sourced food as well, which we know, for all sorts of reasons, will have environmental benefit but is also likely to have a health benefit—how we can encourage that as part of our procurement processes as well. I haven't got the figures in front of me, but there has actually been—. I suppose the NHS is the biggest opportunity, just because of the scale of it. I think there has been quite a significant—I was quite surprised to see the figures; I don't have them in front of me, but I'm sure we can share them—upswing in locally sourced, Welsh-produced foods, which I think is a positive.

Cost is always an issue there, isn't it? More locally sourced food tends to cost a little bit more than other food. I was just interested, with the review that's being done, if the cost element is being factored into that as well.

Chair, it might be helpful if we just let you have a note on the scope of that review. I'm happy to do that.

I think that'd be very useful. Lovely. I just want to move on quickly to physical activity. I'm just interested, with the ‘Healthy Weight: Healthy Wales’ strategy, do you think that has helped drive up physical activity for children and for adults? How have you measured success in whether, actually, more people are doing physical activity because of the ‘Healthy Weight: Healthy Wales’ strategy?

Yes, we know that it has, actually, and it's good to be able to point to a specific. So, we know that three quarters of adults report feeling that they have sufficient opportunities to be physically active, and that's the highest—. It's obviously self-reporting, isn't it, but that's the highest level of data we've had since 2020, when the survey was instigated. So, that's positive. And we also know that the numbers of adults reporting that they hadn't been physically active, or significantly active, in the last week has gone down. So, last year or the year before last, it was 19 per cent and, a year on, that's 13 per cent. So, that trend is going in a positive direction as well. And in a number of ways, as you will probably know, ‘Healthy Weight: Healthy Wales’ directly funds some programmes that are about physical activity for particular cohorts.

How does that work? I've talked a lot about cross-Government in my contributions today, because it is a cross-Government issue. How does that help fund elements like Sport Wales and other organisations, because that's in a different portfolio from yours? But they are key, aren't they, in delivering access to physical exercise at a club level, which we know, actually, is probably the more proven way of actually reducing obesity rates, actually getting people more physically active and actually increasing walking, doing that NEAT exercise, as they say, which is exercise you don't really know that you're doing, but you do on a day-to-day basis. I'm just interested how does ‘Healthy Weight: Healthy Wales’ support those organisations, because they're a key delivery arm of the Government, aren't they?

So, there's a number of ways. There's a specific intervention, which we fund, called Fit Fans, which is specifically around physical activities normally delivered through football clubs. That's funded through ‘Healthy Weight: Healthy Wales’. There's also a particular initiative for physical activity for post 60-year-olds. So, there are those two programmes. Obviously, we fund Sport Wales as well, and we are establishing—or they have begun to be established—sports partnerships, which are local initiatives that cover all of Wales and bring together health boards, local authorities, housing associations—again, big local players—around increasing levels of physical activity, and that's, again, funded through the strategy. So, there are many ways, actually.

Are there ways— ? There was talk, from Government policy, about extending the school day at one time—I might be incorrect, but I think it was when you were Cabinet Secretary for education. I'm just interested—most schools would like to put on more physical activity for pupils, perhaps, but they struggle within the academic day—about doing it in the evenings. There is an element where health could help with budgets around that, isn't there, because it's a cost saving across Government, if health actually invests in education, in schools, to put on sport and activity for young people. We know that only 39 per cent of young people are actually engaged in sport outside of a school environment. So, I'm just interested in how health can help education within education settings to actually provide more opportunities to provide sport, because the education main expenditure group is under pressure, as I know your MEG is. But I can imagine that it may be a way of actually having a cost-saving element across Government in this area.

There are a range of ways already. Those two portfolios are ones where there's a number of ways in which funding passes back and forth. You've got Designed to Smile at one end. Even at the higher education level, actually, there's a cross-over, so there's a lot of thinking constantly in that space about the level of support that we provide to one another.

I think you're right, though—when we piloted, for a period of time, extending the school day, actually, a lot of the activity that ended up being delivered was around physical activity, and there was really good—. I mean, what it told us was there was a huge amount of positive—as we all know, anyway, from our constituency work—a huge amount of activity already in schools in this space. But I thought it was really positive to see local clubs coming into schools to work with schools. There were challenges with that pilot in the end because of the scale of funding that's required to deliver that. Frankly, whichever MEG it comes from, it is quite significant. And there's also the question of unintended consequences, where schools already doing this struggle to fit in with some of those other ways of delivering the policy. So, it ended up being quite a complex policy pilot.

I always thought of it as an interesting concept because it is, as you say, a cross-Government element, because there's the transport element as well, and the costs for school and transport. So, every Government department has got to feed into this, hasn't it? From a personal perspective—

I think, in more benign funding times, it might be something that a Government would come back to, but we're not there, I'm afraid.

Yes. Keep on watching the brief on that one. Diolch, Cadeirydd.

Thank you, James. Joyce Watson.

I just want to pursue a little bit further where James left off. We've invested an awful lot of money in new schools—I mean, significant money in new schools—and, again, coming back to planning, which isn't your remit, building community schools and acquiring as much land outside as possible. So, you know, going forward, when schools are being built, that, in my view, should be a consideration because community schools with available land, of course, can feed into what we've just been talking about, and sharing their facilities in the localities and making them accessible to everybody that lives there should they want that to be the case. And, of course, leisure centres are critical, and we know they're closing—many of them are closing. I'm going to leave that in the air because that wasn't really what I was going to ask you in the first place. What I am going to ask you, in the first place, is—. You've talked briefly about school meals, and the question that I have is about the regulation on school food nutrition in line with the latest nutritional standards and guidelines, and the updated current standards. So, what is the Welsh Government taking into consideration as part of that review and how is it taking into account, quite importantly, the views of the children?

That will be going out to consultation in the next few weeks, I think, actually. And there will be specific—it's not my policy area; it's the education policy area—opportunities for children and young people to feed in their views. Obviously, that's critical. That's part of our approach to consultation on our children's rights scheme, in any case, so that will be baked in, if you like, to the consultation process, and it will touch on the nutritional content and, you know, portions and all those questions that we touched on a little bit earlier.

And the other evidence that we've had is that, even though there are current nutritional standards for school food, compliance isn't being scrutinised. Moving on from that, we're going to roll this out even further, so how are the nutritional standards going to be enforced and will that be considered as part of this new drive?

Yes, so monitoring, evaluation, compliance are all part of the regulations that are going to be consulted on in the next few weeks or months. As I touched on briefly earlier in my answer to Mabon ap Gwynfor, the liability or the responsibility for complying depends, you know—. It can be at a local authority level, or school, depending on how school food is commissioned, if you like. And, obviously, as I mentioned earlier, the WLGA play a role in supporting schools to deliver in compliance with the regulations, and that's really valuable work.

And, of course—and this is going to be the final thing from me—a lot of school kitchens have closed, so a lot of schools now are not actually cooking anything on site whatsoever; it's being brought to them from kitchens elsewhere. So, maybe, when we're building new schools, we need to think about those facilities as well.

I don't want to stray too much into my former portfolio area, but I do think that some of those models that involve more centralised provision can also be ways of delivering healthier school food. So, I think it's not necessarily the case that the mechanism for provision means that you're going to be serving more or less-healthy food. There are definitely good examples in Wales where a more centralised service—I'm thinking of the Vale of Glamorgan, for example, but there are other examples—also enables, you know, healthy food to be provided in schools. I think both things need to be looked at separately, probably.

Okay. Cheers.

Thank you. Cabinet Secretary, the evidence that we've received, and work I've undertaken myself, all point to the position that no country in the world has got the silver bullet when it comes to tackling obesity. But when it comes to developing policy and strategy yourself, are there any countries that you've looked at where you see good examples that will help you in terms of developing policy?

So, as I mentioned at the very start, I think I would agree with you. The evidence, internationally, is that there is no country that has been able to, as it were, reverse the growth, but there is evidence of countries having success in, at the very least, slowing down and, in some cases, reversing the growth in childhood overweight and obesity. I'm thinking, in particular, of Amsterdam in the Netherlands, but also Finland. I think there's some experience from Massachusetts as well. And, actually, that regional approach, with a whole-system approach, touching on the wide variety of things we've dealt with today, is how they've been able to make progress. And those are exactly the levers that we have in play here in Wales. So, I think the mix of interventions is the right mix, and there is good international evidence of that.

Is there anything you can specifically point to in those countries you've outlined, where you have got specific examples that you want to dig into, apart from the regional approach you've mentioned?

Yes. So, some of the family based interventions, so some of the work we were talking about earlier around PIPYN, working with, you know, a family focused approach to intervention, but also issues around the built environment, so opportunities for play—playgrounds specifically. That's a huge area of focus for the Government. Not my portfolio, but you'll be conscious of that already. But also on active travel. And then, in the way that we were talking about earlier, how curriculum and the life of the school can be adjusted to elevate, if you like, healthy school food.

Any specific—? You’ve mentioned those examples. Are they emanating from any particular country?

We can probably let you have—

No, okay—

Amsterdam and Finland, I think, are the two examples, probably, yes.

Okay. And John.

Chair, I know we've got two minutes left, but I'm just thinking about what I guess is a huge picture, really. The health service faces a set of very big challenges, doesn't it—an ageing society, things like obesity and diabetes and much else—and many people see the sense of moving to the more preventive agenda for all of those things, and everything else, really. Piecemeal things happen, but that huge health budget—90 per cent of it is still in the acute sector, really, isn't it? I know it takes a long time to turn things around, but until we start making significant progress on changing that equation, where the spend takes place, and moving to that more preventative agenda, so much of what we do, what the health service does, is going to be firefighting, isn't it, rather than getting on the front foot, as it were.

Can I just bring Mabon it as well, then I'll come to you for your last word, if that's all right?

Yes, certainly.

The point you were making, John, in relation to prevention—I absolutely agree. You might remember, when I was last here, I was talking about the work we're doing to get a consistent understanding of how prevention is being defined throughout the system, about how resources are allocated, so we can then have a very consistent approach across Wales. But I think you're right to say, at a time when resources have been very constrained, the system looks at that point were the pressure is most immediate, and, inevitably, that's in the secondary care sector, because it's about the urgency of people's need. But that absolutely does come at the cost of that long-term investment, and I think obesity is probably the most vivid example of the balance that we need to get back to.

Thank you, Cabinet Secretary, and for your officials for attending this morning as well. I would be interested, actually, if there are any international examples that you've already got in written form that you can provide to us. That would, obviously, help our consideration as well. But diolch yn fawr iawn. Thank you for being with us this morning, and we'll take a 10, 12-minute break.

Croeso, bawb. Welcome back to the Health and Social Care Committee. We move to item 3, and this is the final evidence session for our inquiry into the prevention of ill health—obesity. And we have two final witnesses for this session with us, and I’d just be grateful if you could both introduce yourselves, just so we know who you are. Tracy, I’ll come to you first.

Thank you. Tracy James, Torfaen County Borough Council—catering manager for school meals.

Thank you. And Judith.

Judith Gregory, education catering business manager for Cardiff Council. 

Thank you, both, for being with us. We really appreciate your time this morning. So, perhaps if I ask an opening question, and other Members in the room will jump in with other questions as well. How positive has the response been to the introduction of universal free school meals? Who would like—?

I'll start off with this—

Judith. 

—and then, obviously, Tracy can jump in. So, in terms—. Obviously, we've got a number of stakeholders within the school meals industry. From school leaders, there have been mixed reviews, mainly positive and actively encouraging uptake. Obviously, the implementation was a very quick turnaround, so that did have an impact on schools in terms of getting everything ready for the roll-out. And the negative reviews, I suppose, are that some schools are seeing that the introduction of universal free school meals has had an impact on their budgets, because they're seeing a reduction in school budgets and they're seeing that that could possibly be a reason. And then the other effect, insofar as the school leaders are concerned, is the fact that, obviously, when they go up to secondary school there is a real difference, because in primary they've got the universal provision and then also a free breakfast scheme as well, so they are missing out when they get to secondary school.

Pupils—a lot of positivity. It's becoming the norm now. Obviously, with the roll-out being completed, it's becoming really embedded in. There is a lower uptake in terms of schools than we were expecting, with some pupils still providing a packed lunch. And the feedback from schools is that the pupils will engage with healthy foods in schools, but in reality they prefer the more unhealthy foods that they get outside of the school environment.

Parents are very much pleased with the financial savings. Obviously, the benefit as well is the additional jobs that the programme has created, and obviously it's making things equal for pupils in schools now, when previously we had the benefit-based free school meals and the paid meals, so there was that difference, so there is much more equality as far as pupils are concerned. Is there anything else, Tracy, that you wanted to add?

Don't feel that you have to come in. If you agree with Judith, then don't feel you're obliged to come in, Tracy, but is there anything you feel that you want to add, or disagree with, or have a different view on from Judith? You're on mute, by the way. I think just if you leave yourself off mute, then I think the—.

It keeps jumping back to mute, for some reason.

Does it? Oh, that's my fault—probably the technical team are doing that. You shouldn't have to press anything at all—sorry. My mistake. Tracy.

I think Judith covered that very well. There was a pilot programme, which a charitable organisation called Nesta carried out. So, there is some—. Although our evidence is obviously anecdotal, there is some firm evidence, which is in the Nesta report. I don't know if anybody's had sight of that report yet, but that is quite interesting reading, so that could be something to support some of the information Judith has just given you.

What are the key—? I have not read that, Tracy. What are the key issues in that that you think are relevant?

It was a pilot programme, with only three authorities involved, so it doesn't capture the whole of Wales, but it did give an impartial view, then, I suppose, where they interviewed parents, pupils, school leaders, and there are a lot of statistics in there as well as to the results that were found. So, it doesn't add anything to what Judith was saying; it just backs up what Judith was saying.

Okay, that's helpful. Thank you. Lesley, do you want to come in?

Yes, thanks very much. I just wanted to look at the nutritional value of school food and what you think the Government should be doing and what you think you should be doing as local authorities. I was saying, in an earlier session, when I was a school governor—and I appreciate that this is probably about 25 years ago—you never saw a peeler in a kitchen. There was no fresh veg. It was all deep fat fried et cetera. Would you say that that is still the case? Would you say we've moved away from that? How have universal free school meals impacted on the type of food that's being served in school canteens now?

Tracy, do you want to do that one?

Yes, I'm happy to do that. Well, the healthy food in schools Measure was introduced in 2014, so I think you'll find, since that time, there has been a lot of work going on in schools with regard to the provision of fresher fruit, vegetables and meat products. So, there is more cooking that goes on in schools these days. The universal free school meals provision hasn't changed anything in that respect, because it was already there since 2014. Does that answer your question?

It does. So, I was in a school in my constituency about a month ago, and I didn't see any fresh veg on plates. So, is it monitored? Would you say that the monitoring is adequate? Who goes into the schools to make sure that this is being done?

Judith, or—?

I don't mind. Yes, I'll do it, if you like. So, all of the menus from primary school are submitted to the WLGA for a certificate of compliance, and then, obviously, they're nutritionally analysed, and then a gold standard, obviously if it meets all of the requirements, is issued to that local authority. But, obviously, that is a paper exercise. So, at the moment, there's nobody actually going into the schools from a WLGA perspective, but, obviously, all local authorities will do their own monitoring in-house by their own staff to ensure that the regulations that Tracy has mentioned are complied with. So, it's down to individual local authorities to monitor it on a day-to-day or a week-by-week basis, but the actual menu that's published will be nutritionally analysed and, obviously, checked for compliance by the WLGA.

Do you think there's some conformity—[Interruption.] Sorry. Do you think there's some conformity of menus across Wales? So, for me, what I'm trying to get at, I suppose, is: do you think the Welsh Government should be setting out, 'These are the school meal menus'—a bit like they did in hospitals a little way back?

I'll just bring in Mabon with a question as well, and I'll come back to either of you. Mabon.

Yes, sorry, just on that as well, local authorities do their own in-house monitoring, so, where are they reported—which scrutiny committee would that information go to within the local authority? Do you know who monitors this in-house? Is there a political oversight?

It would be a local arrangement within each local authority, because each local authority operates their school meals service in a slightly different way. So, it's down to each local authority in terms of any in-house auditing that they are doing. And in the same way, in terms of the previous question about a Wales-wide menu, we're all aware that schools are all slightly different. Within a local authority, pupils from schools next door to each other would have—. You know, some items would be more popular than others off the menu. And likewise, from a local authority perspective, there are differences between local authorities. So, a Wales-wide menu wouldn't necessarily work for that reason, because we do personalise it, depending on our own individual local authorities and schools.

Joyce, do you want to come in there?

Yes. I was looking at—. We talked about the 'Healthy Wales' delivery plan—somebody mentioned it earlier on—for 2022 to 2024, and the Welsh Government has committed to reviewing the regulations on school food nutrition in line with the latest nutritional standards and guidelines, and also to update current standards. What do you think that the Welsh Government should take into consideration as part of the review, and how would you like to see the views of children taken into account when that happens?

Tracy, do you want to—?

Tracy.

Yes. So, the second part of the question—the children's point of view—that is quite a contentious thing to actually carry out. Again, if I refer back to Nesta, when we did the pilot project of encouraging everybody to stay for school lunch, they used some unique techniques within the schools, which took a lot of time, a lot of effort, but actually they spent time with the children. A questionnaire I don't think would be the perfect answer. As we know, the children will tell you the correct answer; it doesn't mean that is the answer that they actually believe is right. Whereas, with the Nesta project, they used, I suppose, little puppets and different things to actually get the information out of the children as to what they wanted and why they wanted these certain things on the menu. So, I think a questionnaire's probably okay for schools, as in school leaders, but, with children, to get a more accurate picture, a better way of dealing with it would be to actually go into the schools and spend time with the children. School council meetings are great for things like that; we try to cover most of our schools, although not everybody always wants to engage. But I think it could be done with the assistance of people who are actually the experts in dealing with children and getting the information out of them, rather than just a questionnaire, or just us as a local authority caterer.

Sorry, what was the first part of the question again?

The other part was: as part of the 'Healthy Weight: Healthy Wales' delivery plan in 2022-24, the Government's committed to reviewing the regulations on food nutrition in line with the nutritional standards and guidelines. So, my question was: what should the Welsh Government take into account?

I think there's quite a lot of work going on at the moment with regard to the review of the regulations. Welsh Government are taking into account currently scientific guidance, practical considerations and obviously the financial considerations, but they're looking under the themes of food and drink standards, which we already have, and just the tweaking of those. They are using Public Health Wales and local dieticians to assist with that work. I think they're also trying to look at the whole-school approach as part of the new regulations, although there's not been much input from local authorities with regard to that to date.

Engaging with schools: I suppose, to date, there's been more onus on the local authority caterers to do that. But I think they should consider things as well such as procurement and sustainability. There is a lot of work going on with regard to Welsh produce, but, obviously, the financial restrictions come into play with that as well.

Special diets: that is another large topic, because, with universal free school meals, obviously there are a lot more children coming forward that, historically, may have brought their own food in, whereas now parents see their right to have a meal, so we are catering for a lot more in the way of special diets. I would say ours is—. I'd estimate that it has tripled, the amount of special diets we cater for now.

But they also need to consider the conflicting demands with schools, such as, particularly in the secondary schools, reduced lunchtimes, reduced space for the children to eat. A lot of handheld products are used in secondary schools, which—. As a caterer, we would like to see the children sitting with a plate and an actual meal.

And also the wider healthy eating agenda: I think they need to consider that, because, as school caterers, we've had guidance, we've had legislation in, for over 10 years. The wider healthy eating agenda should take into consideration preventative work outside of schools, and possibly preschool—well, not possibly, definitely preschool—because we're seeing a lot of pupils coming in, and it's very difficult to change their mindset when they arrive in school, because the first four or five years of their lives, they've eaten, shall we say, alternative foods.

Thank you. James.

I'm just interested in how healthy eating is actually promoted more in schools. I've got a young niece, actually, who's in high school now, and all she wants to eat is burgers and everything. So, I'm just interested in how healthy eating is perceived in schools, and, actually, how local authorities can assist with making healthier options more available, and what's being discussed in school to actually explain, 'If you're eating these types of food, it can have these negative consequences.' I think there's a role there for the local authority. I was a local authority cabinet member at one time, so this was something I used to raise quite regularly.

I think this comes back to, as Tracy has mentioned, the whole-school approach. Obviously, we, as local authority caterers, can provide the healthy food for pupils that is compliant with the guidance and the regulations, but, at the end of the day, then, it's their choice as to whether they actually take that. But, by adopting a whole-school approach, where, obviously, all of the nutrition education that's provided as part of the curriculum is reinforced with pupils—. Also in terms of whether, especially with secondary schools, they have a locked gate policy at lunchtime or whether pupils are allowed out at lunchtime—that's another thing that needs to be considered. As I say, we can provide all the healthy food, but it's down to the individual pupils whether they choose to eat it, and it also is affected by the culture at home as well, in terms of the food that they receive during their time in the home environment.

But, back to Lesley's point, which she made earlier, about no vegetables on the plates, it is a choice, isn't it, that the local authority makes, and certain schools, about what they actually do put on plates. So, a school could basically turn around if they wanted to and say, 'We're not having any unhealthy options on the menu. We will only put this on the menu.' Is that something that you think could be pushed more? Because we do have obesity endemic within our younger population, and something drastic needs to be done, because, if we don't do something soon, all these people are going to end up in the health service in the long term, putting more and more pressure on public services.

I think you'll find, particularly in secondary schools, local authority caterers in general try to put the healthier options on and that often results in schools going out to private contractors, because they deem that that's not the children want. So, schools' governing bodies have the option of going out to an external contractor. We sort of push ourselves out of the market the healthier we provide meals in a secondary school, if that makes sense.

Okay. I just think the work that Jamie Oliver actually did in schools years ago, just tweaking menus slightly, can make such a difference to the calorific difference in food. It's like chicken nuggets, for example. Chicken nuggets that are actually made with proper chicken and different types of coating are about something like 300 calories less than the type of chicken nuggets that you buy. It's like people having jacket potatoes instead of chips. It's amazing how little things can change things, and I sometimes think there doesn't seem to be the desire, sometimes, and the will to do it. That's what I've always found and that's what I find with some of the schools that I go around, anyway. And we do say that it's not what the children want, but, actually, they are still children, and, when adults are running the departments, actually it's what's in their best interests sometimes.

Tracy.

Sorry.

I think—. Sorry, just along the lines of what you're saying, the new guidelines that we're looking at with Welsh Government, they're looking at tweaking the nutritional standards that are already in there, which is a good thing. But I think, on top of that, they've missed a trick in some ways in looking into the ultra-processed foods. They don't appear in there in any shape or form, other than looking at the nutrients of particular foods. That doesn't always include things like, like I said, ultra-processed, and I think we should be considering that, moving forward, in the new guidance, which may help with taking off some of the items that the last gentleman spoke about. 

Thank you—

And I think the other thing to add to that as well is that nutrition education for pupils is very important, because whilst we know that, obviously, the food they receive at lunchtime is the healthy food, so the healthier version of, for example, the chicken nuggets, they don't then understand that, when they eat chicken nuggets outside of school, they are more than likely to be the unhealthier version. So, that's where the nutrition education comes in, and I think that's really important for them to understand that in terms of the type of food that they—making those healthy choices between a healthy food and a less healthy food.

James.

It's a point, but it's around, then, the standard of food you expect, isn't it? If the standard of food you have in school is of substandard level and it's ultra-processed, you'll eat that somewhere else; if you have a good standard of food in school, you expect that good standard of food elsewhere. It's just a point I wanted to make. I don't expect you to comment on it, but it's just a point I wished to make. Thank you.

Thanks, James. I'll bring in John, then Mabon after. 

Just thinking of what you've said about working with families and the importance of the home environment and trying to get good habits instilled in younger children, I just wonder how much work is going on with schemes like Flying Start and perhaps the early years of primary school in terms of working with families and addressing issues around healthy eating. I'm aware of some schools that get children to try different fruit, for example, that they probably haven't tried at home, and very often, parents are amazed that their children will eat them. They often say, 'They won't eat them at home, but they've eaten them at school'. And you can change eating habits in the whole family with some of those approaches. Is there much happening along those lines?

In terms of Flying Start, we don't have any responsibility for that area, that would obviously be the university health board and public health. But some of that nutrition education that I was referring to is incorporated into the food and fun holiday programme, which is funded by the Welsh Government. Children attending those programmes during the holiday times do get those nutrition education sessions, which, as you've just mentioned, are about getting them to try and eat new vegetables and fruit that they would not normally be familiar with. Part of that is that learning process to get parents involved as well. There are family meal bags that are sent home during that holiday period so that parents have got all the ingredients and the instructions to make a healthy meal and do it as a family, with the children as well. So, there is some work going on in that area at the moment, but that's something that really needs to be expanded, and would obviously support with the universal free school meal provision, as well.

I have two questions, if I can, to follow on from James's. First of all, how easy or how difficult is it for you to buy in food that reaches the nutritional standards that you might expect? I'm just thinking that the food is largely, probably, bought in from wholesalers—I don't know, your Castell Howell Foods, Harlech Foodservice, and what have you—do they supply the level of food with that nutritional standard that you want?

Yes. We work very closely with food manufacturers, as well. Part of the review of the healthy eating regulations is that there needs to be—and I think this is planned for a few months' time—consultation with the food manufacturers so that, if need be, they can reformulate their products to be compliant with the new regulations.

That's good to understand. How easy is it to buy within budget? Is it more expensive for you, and do you have to find ways of cutting corners, or are you finding that you have to provide less nutritional meals in some instances, just to keep within your budgets?

Budget is a really big issue for us, because with the introduction of universal free school meals there was that additional commitment that we would be putting more locally sourced food on the pupils' plates. When the programme first started, we were given £2.90 per meal for the funding, but with that additional requirement in terms of the locally sourced food, the local authorities went back to the Welsh Government and indicated that we wouldn't be able to manage on that budget. So, a working party was set up and local authorities provided evidence to that, and then that funding was increased to £3.20.

But obviously, over a period of time now, food prices have continued to increase, so it would be appropriate at this time for us to go back to the Welsh Government again to ask for another increase on that £3.20 that we're getting, because, as Tracy indicated earlier, we're seeing a lot more special diets coming through with the universal provision, and some of those special diets are more costly than our standard meal. As a result of the volume of special diets, some local authorities are now employing a dietician to support with those special menus, because, obviously, they are the experts in that area compared to us as school caterers. We've not got those professional qualifications to be able to do that correctly, so that's an additional cost to the service, in terms of employing dieticians.

Could I just add on to that, Judith? A recent survey by the Food Foundation found that over 1,000 calories of healthy foods, such as fruit and veg, cost £8.80, compared to £4.30 for the equivalent in less healthy food. And since the pandemic and Brexit, we've seen lots of rises in the cost of food.

Thank you. John and then Joyce.

That figure you mention is £3.20. It's not uprated annually, then, in line with inflation—no. You just have to—

No. That was introduced in January 2024. And, of course, that £3.20 is not just about food; it includes the food costs, the labour costs and the overhead costs of providing the meal service, so it is a really tight budget.

It just seems odd that it's not at least reviewed on an annual basis in line with inflation for all of those component parts that you mentioned. Could you just say a little bit more about the significance of special diets? Most of that would be health related, then, would it—you know, gluten free and that sort of thing, and allergies?

Yes, for health reasons and those children who are allergic to certain items. 

There is a significant increase as well—because, obviously, this is universal, so we have to be mindful of the Equality Act. There is a significant amount of pupils with autism whom we find are now also staying for school lunches who previously wouldn't have stayed. Add those to your medically prescribed diets, and it has mushroomed, I suppose, in local authorities.

Is there an element of provision not because of health factors but choice, in terms of vegetarian and vegan options?

Yes, across Wales we would all be providing those options.

Joyce, and then, lastly, it'll be Lesley after that, and then we'll have to conclude things.

Just finally from me, following on from John, food allergies for some children are life threatening, or potentially could be life threatening, so how are you managing those situations?

We've all got procedures in place. We take evidence from medical professionals in terms of each child. A report is submitted to the local authority and then the person within the local authority will develop a diet specifically for that child. That person, as I say, for many local authorities now is a dietician. That information is then sent out to the schools—to both the school and the kitchen manager in the school—and then that pupil, when they're ordering, coming through the servery, is identified as requiring that special diet and they are given the food that is appropriate for their diet.

Thank you. I'm just looking to see whether there are any other pressing questions from Members. No. In that case, Tracy and Judith, can I really thank you for your time this morning? Is there anything else that you want to add before we complete the session—anything that you think is important for us to be aware of as we seek to make some recommendations around these issues to the Government?

Monitoring, I think, could be strengthened hugely. It’s almost, in a nutshell, non-existent in respect of output. The monitoring of provision is there—Estyn, I think, have been tasked with a slight element, but it’s very small. So, to ensure provision is compliant, I think the Welsh Government needs to be considering a body to monitor provision within all schools.

Who would do that?

There are agencies such as WLGA—somebody who's impartial. Whilst you've got some authorities who are diligent and will have audit systems in place, there may be others, and certainly there are private providers, who are not monitored in any shape or form. So, maybe an agency like WLGA or similar.

Okay, that's interesting. Thank you, Tracy. Judith, any last comments from yourself?

No, I think we've covered all the important parts.

That's fine. Thank you. Thank you, both. We'll send you a transcript of the proceedings from this morning and you can review those, and if you think there’s something you want to add we’d of course welcome any additional comments you want to make as well. Diolch yn fawr iawn. Thank you for joining us this morning.

We move to item 4. There are four items to note this morning: there’s correspondence between the NHS Wales chief executive and the auditor general regarding the review of cancer services; there’s correspondence between the Cabinet Secretary for Health and Social Care and the LJC Committee regarding the inter-ministerial group for health and social care; there’s correspondence from Public Health Wales regarding expenditure on tobacco control; and there’s correspondence from the Petitions Committee. Are Members content to note those papers? Yes, they are.

In that case, we move to item 5. In accordance with Standing Order 17.42, I resolve to exclude the public from the remainder of today’s meetings, if Members are content with that. They are. In that case, that brings our public session to an end today.