National Assembly for Wales

Croeso, bawb. Welcome to the Health and Social Care Committee this morning. I move to item 1: we have apologies this morning from Lesley Griffiths, and I'm very pleased that Jenny Rathbone is substituting for Lesley this morning. So, welcome, Jenny. And if there are any declarations of interest, please state them now. No.

I move to item 2, and this is in regards to our inquiry and our evidence gathering as part of our inquiry into the prevention of ill health—obesity. And this morning, we have on our first panel today—and I'd like to welcome—Dr Kellie Turner and Dr Claire Lane. So, thank you for being with us this morning. I wonder, if you'd just like to introduce yourselves just for the record.

Yes, of course. Thank. Hi, I'm Dr Kellie Turner, I'm a clinical psychologist and I'm representing the cross-Wales psychologists working in weight management.

Hi, I'm Claire Lane. I'm also a clinical psychologist and I am also representing the cross-Wales weight management psychologists.

Lovely, thank you. I'm going to start with a very obvious question to us, as committee members, but what is the role of psychologists in weight management?

Good question. [Laughter.]

I hope you know the answer to that, otherwise the rest of the session is going to be difficult. [Laughter.]

Yes, I definitely know the answer. I think, quite often, people think that psychology is just about giving people therapy and helping them to manage mental health, emotions, things like that. But psychology is the study of human behaviour, and I guess, with any kind of lifestyle thing, there is behaviour attached to that. So, part of our role, I would say, is about doing therapy, but I'd say that a lot of our work is actually about psychologically informing some of those interventions. So, it could be on the level of understanding behaviour and helping to change behaviour, but also understanding how people present to services and the kinds of things that impact their presentation, their health and their weight. Would you add anything to that, Kellie?

Well, I'll tell you what, I'll add to my question as well to Dr Turner: are all patients who are referred to psychologists in terms of weight management services—? Who is eligible for support? 

So, I suppose, currently, thinking about the set-up of services in Wales and across the UK, I believe, people eligible for psychological intervention would probably be presenting at our level 3 services, so specialist multidisciplinary services for more complex weight management concerns. 

I suppose, thinking about the people who we might see, I work with children and young people, and Claire works with adults on weight management, and it would tend to be, I suppose, and Claire might be able to add to this, but I would tend to see young people who are struggling with maybe emotions and eating, and eating for comfort or possibly disordered or binge eating at times. I would say they also may be struggling with their self-esteem and their body image, with that impacting on and making it hard to make changes with weight management. So, things like affecting their mood, affecting anxiety, making it hard to go out and do things that matter a lot to them, and being able to create and maintain good social relationships. I can't speak for Claire, but I see a lot of bullying. I suppose, yes, I've worked in adult as well, and I've seen lots of people come through who are struggling with really traumatic events in their lives, with bullying being one kind of event that people talk about. So, those are the kinds of people who I might see.

A question, I suppose, to both of you: are services across Wales equitable? Are there gaps? Well, Claire's nodding, so tell us where there are gaps in the service, and where perhaps there are not services available and how perhaps that could be addressed.

I'm not sure what the position is with Swansea bay at the moment, but certainly, until recently, they had no adult weight management service at all. They have a paediatric service there, and I think—

Should they have a weight service, though?

Sorry?

Should they have a service?

They used to have a very small pilot service, but unfortunately, further resource wasn't kind of put to that, and it wasn't sustainable.

And it's not a requirement for them?

I don't know. I think in terms of the all-Wales weight management pathway, I think the answer to that would be 'yes', and I know it's something that they're striving to work towards.

Right, okay. Sorry, I've interrupted you. [Laughter.] Tell us about the rest of Wales.

So, across our geographical locations, we have different kinds of service set-ups, so I know in places like Hywel Dda, there is quite minimal resource there, and they've learned to do a lot with what they've got. In some services, in terms of psychologists, you've got more psychology support in those services; in others, you've got considerably less. I think, for of all services, there are challenges associated, and the amount of resource and where that resource is allocated varies between health boards. So, in some services, you might have a lot of dieticians. In some services, you have physiotherapy; in other services, you don't have physiotherapy. In some services, you have quite a few psychologists; in other services—a bit like mine at the moment—you have one. So, yes, it's variable at the moment.

So, equitable access is an issue across Wales, but in terms of demand and capacity, is there anything more you can say in that area? Especially perhaps where there are sufficient psychologists available, but tell us about the demand on those services where psychologists are available.

I'm not so sure in terms of paeds, Kellie, so maybe you could kind of let us know about paeds, but I know in terms of adult services across Wales, at the moment, particularly since the introduction of GLP-1 medications, and people wanting to access those, there is a lot of demand, and I think most of the services that I'm aware of are struggling to meet that demand. We don't have anywhere near enough resource to be able to do that. That doesn't mean that we're not trying to make the best of what we've got; we're trying to think of really innovative ways to be able to enable access for as many people as want to and need to access those services. But there's no way that we can meet that demand currently, and I think that, in some areas, the demand was great even before the introduction of things like GLP-1 medications. Kellie, do you want to say what it's like in paeds?

I was going to say that there are only three health boards that I'm aware of—or is it three; it could be four—in Wales that have a dedicated children's service for weight management. So, yes, it doesn't feel equitable, I guess. I'm under the impression that some of the health boards that don't would probably be places with a lot more inequity and more deprivation, which then we notice comes along with higher rates of difficulties with managing weight. So, yes, just echoing: difficult, inequitable.

On demand, I guess—only speaking from my experience, from what I can see—it's less in the child services than in the adult services. There are lots of understandable reasons around that, because it's quite tricky for children and families to maybe think where they're at with motivation. It's different for an adult who might seek that for themselves. But, yes, there's still a fair bit of demand, and I've seen referrals increase since I've been in the service.

There are couple of Members who want to come in before I move to Jenny Rathbone. James, and then Mabon. James.

Just on the weight management services for young people and children, you say there are only three or potentially four health boards across the country that do that. The ones who don't, do they procure the service from other health boards? Do they send children to those areas, or do they send them across the border into England, for example? Because I'm not aware of Powys Teaching Health Board having one, for example, but I could imagine, because they are a commissioning health board a lot of the time, the same as I imagine Betsi probably does, them sending people across the border into different health authorities to get that level of treatment. Are you aware if that happens now?

When I started working as a psychologist in child weight management, I was aware of some service level agreements. I'm not aware of any at the moment, so, yes—

It's a really good question, because the question for me isn't really about relevant psychologists based in health boards, it's about the access to the services, which is the most important aspect. So, I think you've answered that. In some parts of Wales, where there are psychologists available, there's a service, and if there are not in the health board, there's not. I think that's effectively what you're saying.

I believe so, yes.

Yes.

Yes, because sometimes, with all due respect to some health boards, if you want the best service you have to travel for it, don't you? Even though not every health board has it and, say, Cardiff and the Vale do, but Swansea don't or Aneurin Bevan don't, if they can procure that service into Cardiff—I'm being hypothetical now—where there is the best service, is that the best outcome for those young people, rather than each individual health board doing something and perhaps not doing it as well as another one?

You answer to that is pretty significant, about the inequality of services across Wales, yes. Mabon ap Gwynfor.

Thank you for that question. That question is my favourite. So, working as a psychologist, what I see is that, obviously, I think that anyone who is living with social deprivation and poverty, that in itself is traumatic but also, if you look at adverse childhood experiences, you are more likely to experience more of those adverse childhood experiences. Living through those kinds of circumstances and living through adversity, as well as, perhaps, not having the same life chances in terms of things like education and access to things, they all come together. I think what's really important, and this is some data that came out of the Cardiff and Vale weight management service, because they actually audited and surveyed their patients—I'm probably not going to get exactly the right numbers, but I certainly know the trend—if you look at the national average in terms of people experiencing adverse childhood experiences, I think it was four or more childhood experiences and, I think, within the population within weight management, you were looking at about 60 per cent. Kellie, does that sound about right? It's somewhere around that sort of figure in comparison with about 20 per cent, I think, in the general population.

Within that, when you look at childhood sexual abuse or growing up with a parent with a mental health problem, and sexual abuse is the one that always stands out in my mind, nationally that's around 10 per cent—something like that. In the Cardiff and Vale data, what we saw was that that was around 30 per cent. I tend to think we know that these things go alongside things like social deprivation. I work in Cwm Taf and it certainly matches what I see in clinical practice. So, what we need to understand is that just the adversity in itself can impact weight through the release of things like stress hormones and chronic stress, and there is also using food as a means of coping with life. And, actually, if you've managed to get through a set of circumstances like that and come out the other side and food has helped you to get there, you can kind of say that, well, actually, you've done pretty well, in a lot of ways, it's just that maybe that coping strategy is causing you some health problems now, if that makes sense. So, it's almost like a kind of patchwork—I describe it as a patchwork; you have one patch and then something else gets sewn onto it and all of that makes up like a blanket, or whatever, and it all fits together. Kellie, I don't know if you want to comment from what you see on the paediatric side of things.

Just briefly. I'm just a bit conscious that we have to move on to some other subject areas, but if you've got a brief comment, Kellie—

Yes. I would agree completely with what Claire said and just say that I tend to see referrals from areas that are more deprived, a high proportion of families and young people. And yes, just agreeing, really, with the ACEs and poverty and those things really impacting on people and how they regulate together as a family, how available parents can be for their children and, therefore, the coping mechanisms we go for.

Thank you. Jenny Rathbone.

Thank you. I represent an area of Cardiff with multiple super-output areas of deprivation. There's a public health emergency going on across the country, involving all classes, but I appreciate that the problems are even more extreme amongst people who are struggling with poverty, as well. I really want to look at how you advise the midwives and health visitors on how they need to approach the importance of making the best start in life in terms of diet and breastfeeding, which is a challenging issue, because people's mothers didn't breastfeed, so there's a huge education that I imagine midwives don't have enough time to engage with. But, are you able to say anything positive about the impact of the Flying Start programme in terms of establishing healthy eating? Are you aware of any evaluation that focuses on that, because the whole point of Flying Start was to give people more of the services that they needed?

I don't know details, I'm afraid, but I am under the impression that Flying Start has been a helpful thing for lots of parents.

In terms of establishing healthy eating?

Well, if I may, I guess, for me, it's about wellness rather than just healthy eating, or weight. There's lots of evidence to show that things that help us feel better, more connected, more community, mean that we feel more regulated. And when our body systems are feeling more regulated, we're able to engage in things that matter more to us in life, and it becomes a virtuous cycle of well-being, essentially, and health. And it's when we're going through adversity and difficult stuff that our stress system is up, and it makes it harder to make lifestyle changes, it makes it harder for us to be really present with what we're doing, and that includes with parenting and looking after young children—it's a really hard job, you know, it's a really hard job; it takes a lot.

I think, actually, just to piggyback onto that, we know that when somebody's threat system is activated, it's harder for them to take on things like advice and guidance and give due consideration to how to manage a kid when they're being really picky with their food, or what food choices to make for yourself. When your threat system is activated, you're in survival mode and stuff that requires a bit of thought becomes a lot more difficult to do. Would you say that's fair, Kellie?

Yes. I believe, as well, that there've been Government moves to support families with access to vitamins and healthier eating—

Well, we've got the healthy food vouchers.

Yes.

The Healthy Start vouchers, I beg your pardon. But until the former Deputy Minister for health had a serious campaign about this, the uptake was atrocious; I think it was 45 per cent, and it's now about 78 per cent, I believe. So, if we don’t start from there—. So, weaning is a really important moment, because otherwise—. We've all read stories about people feeding babies totally inappropriate food, starting with those jars of baby food, which have got sugar and salt in, and are very expensive. What teaching do you give to health visitors to ensure that they're intervening at these key moments? Because otherwise people will simply resort to very expensive manufactured stuff, which is full of salt and sugar, but it could also be a moment where people could clean up their own diets if you encourage people to say, 'Well, if you have a potato and a carrot and you just mash them, that's good for baby.'

I can't give a definitive answer about that, but it seems to me that the starting point needs to be having conversations around why people are making those choices and what the barriers are, and I think, when people are saying what the barriers are, we need to be thinking, 'Well, actually, how can we support them to work through those barriers, because becoming a parent is difficult, it's life changing?' I do pretty well in my life, but when my baby was young, I was all over the place. And I think it's about asking people, 'What are the barriers and what support would you need to enable you to think about some of these things? What is it that makes you opt for the baby food jars rather than pureeing some fruit or whatever it might be? What are your barriers around that? And what would make it feel more important and more doable for you to maybe consider something different?'

Okay, because the biggest challenge we're up against is the multimillion pound food industry—

Absolutely.

—that is constantly telling us we should eat some rubbish that is of no nutritional value at all.

And it provides an easy solution, doesn't it—'Your life’s stressful. Here, just pick up a jar', and it's difficult to compete with that. But I think the answer to that is going to come from the communities that we work with. I don't think that I have the answer on that. But I think that they, probably, do. I think we need to understand what it is, beyond the, 'Well, it's easy,' so, 'Well, what actually prevents you from considering something different?' And I think the midwives and health visitors would be in a great position to be able to have those conversations, provided that they've got the resource provided to them to have those—

Well, they'd have multidisciplinary teams. They don't all need to be super-qualified midwives.

If I may just add as well that, in my work, I've been part of training health visitors and school nurses around the factors impacting on families with weight management, and how we support them as a service, and things like that. And I suppose, from my point of view, I think that's a really great way to support professionals with those conversations and get them really early and support—. We talk about weight stigma as well there, to inform practitioners about how to go about the conversations, because they're difficult and very sensitive conversations. But, in my opinion, there's not enough of that training in practice. If we're thinking about equitability and accessibility, you know, of psychology and of services, I think some really key ways that we can support that, as psychologists, is through things like training on a larger scale, professionals supporting resource sharing across health boards, and doing things like consultation and liaison with lots of other services, joined-up care between services.

But also the ongoing support with that. How many of us have all been on training programmes where we've had, like, one or two days of training, and then that's it? And then we go back into the real world and we're expected to just pick up what we learned in the training room and apply it to what we do. You know, we're thinking about helping our patients, our clients to change their behaviour, but, actually, I think that professionals working with them need support to change their behaviour too, and to actually bring into their own practice the stuff that we might deliver training in. I think that’s something that’s quite often overlooked. And I’ve even tried at work, kind of saying, ‘Well, if I deliver this training, the deal is that you release people to be able to have an hour once a month, where we come back and we talk about trying to use these skills, and we kind of problem solve around what’s made it difficult.’ But quite often, that’s a tall ask. It’s kind of like, ‘Well, no, sorry, we’ve got other priorities’, and it’s just lost.

Okay. So, focusing on prudent healthcare, which I assume you’re familiar with, how do we get primary—? In those health boards where there are weight management services, how do we sort of turn the line around to get more prudent healthcare, whereby we’ve got a team of people who are qualified to do the specific tasks that we’ve identified are needed to be done? Because peer-to-peer support is an incredibly important way—

Absolutely. 

—of getting communities to think differently about what’s best for baby. So, are you aware of any of these weight management services, in the three or four that have got them, that have got multidisciplinary teams? So, they don’t all need to be fully qualified health visitors, because that person probably doesn’t have the time to have these really important conversations with parents.

So, in the child weight management services, we don’t have health visitors or school nurses. We train into those teams.  

You train them. 

Yes. 

But do they then think, ‘How can we realistically do this, given that they’ve got x number of families to get around? There’s far too many people who say, ‘I never saw the health visitor from the minute I left the hospital.’

Yes, and I think—. I’d just echo, really, what Claire was saying about the training that I’ve seen, which is often kind of one-off, or once a year. There isn’t necessarily lots of space to be able to reflect on the things that people are really struggling with, in their practice, or the themes that are coming out, and how we can help them a bit more. It’s that ongoing training of our workforce, and also the workforce well-being, because—

It’s hard work, isn’t it, Kellie?

It's hard work and it's important. We say a lot about resource for weight management services, but also it's about resource for those other professionals. It all impacts on—. All parts of the system impact on one another, don’t they?

Sure. So, just looking at the system, we’ve got this programme called, ‘Healthy Weight: Healthy Wales’. What impact is it having on giving higher priority to something that is now the biggest killer and cause of early death? It’s the biggest driver. So, this is a major public health problem. What impact, in your experience as psychologists, has the ‘Healthy Weight: Healthy Wales’ programme had on changing the way people prioritise what they have to do?

Can I be honest? I don’t think that I’ve seen very much of a change at all—

Thank you.

—in all honesty. I’m aware of the document. I’m aware of the ethos of the document. I’ve yet to see it in practice. And actually, we’re talking about how we can spread the resource. I think that it’s so important to try and get our communities involved in this stuff, because we were talking about this before we met, and, quite often, it kind of feels like we’re trying to mop up while the taps are still on.

I know that when I started my most recent position, one of the things that we would've liked to work towards was actually kind of getting members of our community—maybe people who’ve accessed our services—and trying to kind of build peer support, trying to build good grounding for supporting each other, not just with managing weight, with other things, but also with managing weight. Because I think that probably a lot of people in these communities—. And that doesn’t mean that they come to our services and they don’t feel the benefit and they don't feel great, but, actually, it takes a lot for people, particularly if they’ve had a history of adverse childhood experiences, to actually approach a service and engage with a service, if that makes sense. So, the more that we can do to actually not mean that somebody has to be kind of rocking up through the door to get the treatment they need, the more that we can be encouraging people to support each other and help themselves, the better that might be. But I think it goes beyond what services we provide. It needs to be outside of that as well.

But surely the services have got to change to better meet people's needs.

Absolutely. 

That's what they're all about, isn't it?

Absolutely. 

Okay. Thank you. Joyce Watson.

I want to talk about stigma and discrimination. I'll start with the fairly obvious question: to what extent is weight-related stigma and discrimination an issue for the patients that you see?

For all of them, practically.

Yes, it's huge.

Absolutely massive. It's everywhere. It's in the media, it's when they're walking down the street, it's when they go somewhere and they need to sit on a chair, it's when they need to take public transport. It's absolutely everywhere. I think there are the understandable difficulties and the impact on things like body image, but actually it goes well beyond that. It impacts on people's self-esteem. We live in a society where it's not okay to discriminate against people because of their gender, because of their age, because of their culture or their ethnicity, but unfortunately we're living in a society where it seems to be acceptable to comment on people's bodies. And it's a major hurdle, I think, for most of the patients I see. And certainly—I'm looking at Kellie; I know that they experience bullying from quite a young age, related to their weight, quite often.

Yes, definitely. 

Do you want to add to that?

I was going to say that I find it huge. I don't think there's—. It's very rare in my day-to-day work that there's a young person I've come across who hasn't experienced some nasty comments, rude comments, insulting comments, bullying around their appearance, and that's weight-related appearance. And I think it starts really early as well. As a society, as Claire said, it's in our media, it's still one of the few things that people find it acceptable to comment on. And from a very early age—when people have babies, there's this view that you want them to be bigger, you want them to be chunky, you want them to thrive, but then there comes a point where suddenly it seems like a concern.

In the service I work in, we work from zero to 18, and it's really hard to know when that should become a concern. And then that affects parents and their worries and their anxieties, understandably, and it affects almost their inner confidence to parent, to feed their child and to feel okay with that, and they start questioning themselves. So, I'm not saying that that's necessarily stigma there, but it's just that the focus on our bodies is so ingrained in us from such an early age and, as Claire said, those kinds of messages, the little drip-feeding messages as well as the big ones like the bullying comments, affect our sense of self, they affect a child's internal working model of how they feel about themselves, how they feel about the world, and it starts to feel unsafe and like they're not good enough, like they're different, and it can lead to difficult ways of coping.

So, how do we deal with it? 

Well, I think, in order to deal with that, we need to find a way to help people to conceptualise obesity differently. I think that another aspect of weight stigma is that assumptions are made that people are overeating and they're not doing enough exercise, and actually that says a lot about their character and about the kind of person they are. I see it in healthcare all the time. A patient goes to the doctor with a health concern, and what they get told is, 'Well, you're overweight. You need to go away and eat less and do more exercise', rather than investigating the health problem, and rather than thinking, 'Well, actually, what's led up to this person experiencing obesity?' There are not enough of those questions asked. So, I think that, possibly, the first place to address it might be within healthcare, because actually I think that stigma can be a barrier to people accessing healthcare, not just for weight management, but for other health concerns as well. But I think we need to find ways to get the message through that obesity is so much more complex than just what you eat and how active you are. It’s way beyond that, and actually what people need is support. They don’t need further criticism—shaming people is not a way to help them manage weight differently. Have you got anything you wanted to add to that?

I was just going to add, I agree with what you said about the 'Healthy Weight: Healthy Wales' initiatives. I'm aware of those being pockets of practice, but it doesn't feel joined up. And related, I guess, to that, I was just going to say that it still feels like those initiatives focus quite heavily on calories in, calories out, and we know that that's a model that hasn't worked for years, for decades now.

Have you heard from the patients who you see much evidence of their condition beyond obesity being ignored? Because we took evidence where people were telling us that that was the case—that at the first point of referral, usually the GP, but not always, they were judged by their appearance, which was a huge block, then, in looking for the complaint that should have been looked at.

Yes, absolutely. Absolutely. I see it every day with practically every patient that I work with, to give you an indication of that.

Okay. Thank you.

Thank you, Joyce. James Evans. You're okay—you'll come in later. Okay, Mabon ap Gwynfor.

Yes, I would say so. I think there's a perception of what you would call the people who are the deserving unwell, if that makes sense, and often those are conditions where it's kind of chance. With weight management, I think often the idea is that people have brought it on themselves, which is obviously completely mythical and untrue. It's a lot more complex, like Claire was saying.

Yes, and the thing is, I think with the argument of individuals needing to take responsibility, what we need to understand is that you need to have power to take responsibility and we know that, actually, a lot of the people who we see in weight management services have been quite disempowered during their life. How do you expect somebody to pick up the reins, when, actually, they've never been allowed to climb on the horse?

Yes, we're often—I'm thinking about work in adults at the moment, but sometimes in children as well, we're often not the first place people have come to for support. Often people have been through ways to manage their weight by themselves, and they've cycled and they've found it difficult, and they've come across barriers. And often people have been very successful in the past, but it's been hard to sustain because they're going back into an environment that's filled with difficult decisions to make around food, because of the food companies, and filled with toxic stress. And actually, yes, often this is—I'm thinking of the adult services—the last place that they're coming to and they're looking for something to help, and they've come to the end of their tether. So, I think what Claire said about power and feeling disempowered is completely true.

I would say, from my experience, it varies. I'd say, for the majority of people that I've certainly encountered in primary care, I think there isn't necessarily that understanding there. We do have some GPs who have a specialist interest in obesity who, I think, do understand those links quite well, but they don't always know how to manage that or what to do with it and how to have those conversations with people, really.

I would love to see more psychologists in GP surgeries—not necessarily doing 1:1 sessions, but actually thinking about that broader role of the psychologist in terms of upskilling the team to be able to have those conversations and supporting those teams. I think, within healthcare, I'd say—to an extent in mental health as well, but particularly in physical healthcare—psychologists are seen as something that is nice to have but not really essential to the job. I remember once I said, 'We're not even the icing on the cake; we're like the cherry on top of the icing on top of the cake', whereas, actually, I think we need to be like—. I don't know; it's almost like the cherry needs to be inside the cake, it needs to be part of that patient's healthcare journey. And I think the key is working with those health professionals across, from primary and secondary care, because another concern to me is that psychology is always situated and placed within level 3 and level 4 weight management. Actually, what about level 2, what about level 1? Why are we not there? Why are we waiting for the problem to get so bad and then they see us, rather than getting us in at those lower tiers and actually supporting professionals from other disciplines to be able to help people manage this? I'm not sure if that answered your question or not. I got on a bit of a soapbox there, I'm sorry.

So, the short answer is 'dim'—'no', there's not. There's not anywhere near enough of us, for exactly those reasons that I've said. I'm not sure that I could even put a number on it on the spot right now, but I think if psychologists were tasked with thinking about, 'Well, actually, what's the composition of these teams?', and, realistically, how much of us would be needed to do what kind of work, I think another thing that that would need to be tackled is this idea that psychologists are just about doing psychotherapy with people. Because I would say that that's part of our job, and we're very effective with our interventions— we've got great evidence bases that help us to know what to do with quite complex presenting difficulties—but, if we're seen as that within the teams that we're placed within, you're not going to get your bang for your buck. So, I think it's a good question, and I think it's something that probably deserves a bit more consideration than any answer I could give you now. What would you say, Kellie?

I would add—. I don't know if this feels relevant, but I'm aware that, in places like paediatric diabetes services, they do looking at the workforce and the make-up—I don't know the exact calculation, sorry, but—looking at exactly how much of each kind of staff member they need for the population that they're serving. I could be naïve, but I'm not aware that that happens in weight management services, and I feel like that might be a place to start with being able to put a number on it.

I'm really aware, actually, that services have cut psychology support very recently. It is seen as the adjunct, and I think also it's not just about—as Claire was saying—having services in these specialist kind of areas, but thinking about how psychology can help as a whole. You mentioned mental health, and it's that bi-directional kind of effect between mental health and our physical health. If we can support people on a grander kind of public level, with psychologists influencing public health more—might I go there—to really help people to understand that public health initiatives are also about how—. It's about our wellness and our physical regulation system, really, and being able to feel okay day to day. And that's a really difficult thing in a cost-of-living crisis.

Kellie, you triggered something off in my mind there, just thinking back to the question that Joyce asked about weight stigma. There's been a lot of research done on weight stigma, and there's one researcher who's quite prominent in the field, Rebecca Puhl, and I know that one of the things that she found from her research is that when there was a focus on adopting healthy lifestyle behaviours in order to improve health, actually, the weight management with those interventions was more beneficial than a weight management intervention in itself. So, maybe another thing that needs to happen is the focus—you know, what is the thing that that we should focus on here? If we're talking to somebody, for example—just thinking of a condition, I don't know, type 2 diabetes—about the importance of eating a good diet and how that can help with the management of your condition and how keeping active can help with the management of that condition, rather than being, 'You've got to lose weight, you've got to lose weight.' Because I guess the weight loss is the outcome, isn't it; it's not behaviour that changes. It seems like, when the focus isn't on the weight, people tend to do better, so maybe that's something else that needs to be considered in with all of this stuff.

There needs to be a holistic view of a person and their family. Rather than focusing on just weight, or just this health condition, or just their mental health, we need much more freedom to be able to join those things up.

Yes, 'What happened to you?' rather than, 'What's wrong with you?'

Okay, that was a lot. I'm wondering if you can just summarise your two questions, then.

Sure. So, I don't think that it's a surprise to anybody sitting around this table that we do know that there's a bi-directional relationship between mental health and physical health, and also, I guess, social well-being and personal well-being as well. What I would say in terms of health services, because they're what I know, is: don't you think it's interesting that, the way that our services are drawn up, we look at physical health and mental health as separate things? It feels like anything that happens from here upwards goes to that service over there and everything from here downwards goes to that service over there. The skills that I use as a psychologist I could use in a mental health environment quite easily. I use them in a physical health environment as well. But, actually, for other professionals working in that service, it's not quite like that, and I think it presents barriers. I think about when we've got patients who clearly have a really great mental health need and, as a psychologist, I might refer out for that, because, within the scope of my treatment model and what I've got to deliver, I know that I don't have the right amount of time or capacity to be able to deal with that. Equally, we will get people in mental health saying, 'Well, they're feeling depressed because they're overweight; they need to lose weight, so, actually, this is your bag', and it ends up with services kind of playing off against each other. I think the key is trying to bring those services together a bit more. How we could do that, I'm not entirely sure, but I think if it was something that we were aware of and it was something that we thought was beneficial and we might work towards, I'm pretty sure that we could find a solution, or, even better, actually, our client group could probably help us find a solution to that.

I was just going to add about the practicalities of the joined-up working, and thinking about, even, our systems, the computer systems that we use across the NHS and local authority, and then even mental health versus physical health, are different. That makes it quite tricky, I guess, thinking as a psychologist, to really be able to get a holistic view of someone sometimes and think about, actually, 'What's in their journey so far and how can we make this the most helpful journey for them?' So, even on a very practical level, being able, for different services—and I know even across different health boards people use completely different systems—to find some way where we could have access, or be able to use similar systems for notes and things like that, it feels like it would make a lot of sense, to provide that joint care.

Can I just ask, just for timing, did you have a second part to your question?

I think what I'm aware of is that it comes back to the 'Healthy Weight: Healthy Wales' strategy and the pathway. And I think, for me, although it has some great ideas in it, practically, I'm not sure I see that all the time, and I think what I have seen is pockets of things. I'm very aware that there's been a recent food consultation as well about food and local and sustainable food, and I guess, as a person working in this area and quite familiar with Government strategies, it doesn't feel joined up or holistic, in a way, and it makes me wonder about the general public as well, and what their understanding would be of all these different strategies.

So, what should happen? Are there too many strategies?

Oh my gosh. [Laughter.]

What should happen? What should happen? What should the Government do? Should the Government scrap all the strategies, or should it have—? What should it do?

I'm trying to think if there's a way—. So, I think there's a balance to be struck, really. I wouldn't want—Claire might disagree, and that's okay, but—I wouldn't want to say to scrap all strategies, but I do feel sometimes like there are a lot of different things to keep on top of when you're working in these kinds of areas—mental health and physical health and so on—and I wonder if there's a way that we can provide a more holistic one that brings together—. I think the messages that we have are very similar to the strategies and things that go on in mental health and the things we'd like to see in mental health, and I'm wondering if there's a way we can bring that together. I don't know what, Claire, you might think.

I was going to say that I don't necessarily think that it's the strategies that are a problem, because, when you read through them, you can tell that they're coming from a good place; there are a lot of good things written in there. I think the problem comes in the implementation of those. It’s the taking on board and—

What are the barriers to implementing? The strategies are good, what's in them is good, what are the barriers to those strategies being implemented, in a couple of sentences?

In my opinion, and I’m owning it as my opinion, it’s because the system is already so stressed and people have so many things that they’re trying to do all at once that they can’t make any space for it. Resourcing is an issue. That would be my response to that. I think that’s the barrier.

For me, that just makes me think of the fundamental thing: we need to focus on relational working, rather than tasks or specific 'mental health' or 'physical health'. All of these difficulties, I think, come back to the huge evidence that all these difficulties can be supported by better relational working for our workforce and for the people that we serve.

Thank you. There are two sections to get through. Did you want to come in now, or are you happy to wait until your section?

It's just a really quick question.

Go on then, then I'll come to Joyce. 

I'm just interested in how you manage someone's mental health expectations as they go through a weight-loss journey. I knew you were coming today, and I know a friend of mine would want me to ask you this question, for the simple reason being it can go the other way very quickly. Someone who I know was obese and now suffers with bulimia. They've gone from one pole to the other, because their mental health wasn't managed through the whole process and they're not quite sure what a healthy weight actually is. That person is under severe mental health services now. I'm just wondering how you manage that. It's a young person as well, who has body dysmorphia and ended up being bulimic. So, I'm just interested in how you manage someone’s mental health journey through the weight-loss process, to try and explain to somebody, 'You've now reached a healthy weight', because some people's mental health makes it go the other way—sorry, Russell.

Joyce, do you want to ask your question as well?

You’ve mentioned ACEs many times, and that’s what you’re talking about, I guess. Are you invited at any stage to inform practitioners at all levels that this could be what they need to be looking at, rather than what they see?

Two kind of brief answers on both, please.

I’m a massive advocate of trauma-informed practice. You don’t need to deliver trauma therapy to be trauma informed in the work that you do. I would love more space and capacity in my role to be able to roll that out as widely as I can.

And on James's question.

I think for me, again, it comes back to focusing on weight as the outcome. I’m really sorry to hear about your friend, because that’s such a difficult thing to go through. But also, I think it's quite reflective of other young people that I've seen and worked with. Like I said, I think the narratives we get as a society, the focus on weight and weight stigma, can mean that it is really difficult to think for ourselves, 'What's healthy for me?' I think we get then hung up on those things. It makes us feel not great about ourselves, like we're not good enough if we're not a certain way or if we don't look a certain way, and it can become a vicious cycle, as you've mentioned. So, for me, when working with young people, I'm trying to monitor, as we have therapy or discuss things with parents, how they're feeling about themselves and trying to bring the focus back to what are the health behaviours we're looking at, what feels well for you, rather than what's the number on the scale.

Thank you. John Griffiths.

Diolch, Cadeirydd. I think we’ve already covered an awful lot of ground that very much addresses issues around complexity of obesity, but perhaps there may be a few things that you might want to add. When we look at the complexity of the condition, as you’ve mentioned, beyond what you’ve already told us, is there anything you would like to flag up to the committee in terms of actions that ought to be prioritised, in the short term and long term, to really make a positive impact in terms of obesity in Wales?

Wow, John, that's a big question. 

It is. I'm thinking about trying to inform and educate professionals and the wider public on wellness, and creating services focused around wellness, not specifically weight. That might feel very controversial, sorry, coming from a weight management service. But also, as Claire mentioned, thinking about psychology not being an adjunct to a service, or an added extra, but vital at every level of support. That doesn't mean a psychologist everywhere per se, but psychological skills and training at every level.

And support with that training as well.

You've got health centres starting to develop a little bit in Wales now, haven't you, bringing a lot of services into the community. There's one just opened in Newport East, which I represent, which has physical and mental health services there—a range of practitioners and professionals. If you just had a psychologist spending some time in one of those health centres, and then perhaps time in another health centre, just being shared around, as it were, in terms of the services, might something like that begin to have an impact, do you think?

I think you might need more than one, though. I think, sometimes, when we're talking about that aspect of our work, it sounds like it's really easy to do, but, actually, it's not that easy to do. So, in principle, yes, I think that's a really great idea, and also working to help maybe those services integrate a little bit together, and get those health professionals, from mental health and physical health, working together. Yes, you're right, you don't necessarily need a massive resource, but I think more than one would be good, because it is a lot of work.

Yes, I'm sure it would take some time to get the various professionals aware and thinking and acting in the right way.

Absolutely, yes. I wish I could wave a magic wand and then suddenly they can think like a psychologist, but they've had different training and different life experiences. 

We've discussed ‘Healthy Weight: Healthy Wales’, and I note your views that there are good ideas in there, but in terms of implementation and practical impact, it's not really as significant and effective as it should be. You pointed to some ways in which it might be improved. Is there anything you'd like to add to that? Obviously, it's really important in terms of tackling obesity. I think you've said, Kellie, that it seems to be too much, in the way that it's implemented, about calories in and calories out, when we know that it's much more complex. Is there anything that you'd particularly like to flag up again in terms of what change should happen to make it more effective?

One of the things that I see repeatedly through these strategies is that, quite often, because there's that focus on calories in, calories out, the psychology aspect is seen to be, 'How can we get people to adhere with this calories in, calories out model?', whereas, actually, I think what we need to be doing is helping people to think about things like trauma-informed practice, to be thinking about engaging community groups and peer support, and those kinds of things. I think, sometimes, it's those aspects, and understanding the impact of trauma. It's not necessarily about them needing psychological therapy to recover from that, but we need to understand that people might present to services in a particular way, or they might find it difficult to think about changes, because it involves that logical part of your brain, and needing to engage that. So, I think maybe understanding more about the whole person, rather than just about the behaviours, would be good coming through that sort of stuff. Did you want to add, Kellie?

I was just going to bring it back to what you've been saying, really, but a relational approach rather than a behavioural one, which reminds me a lot of the attachment informed principles and positive attachments, which brings us back to thinking about very early years. If we can support families and people with positive attachments in their lives, it can have huge ramifications for the rest of their lives and their health and their mental well-being.

And also, maybe—just a quick one—something about having those conversations. The National Institute for Health and Care Excellence guidelines on weight management have just been updated within the past couple of weeks, as I'm sure you're aware. There's a really lovely guide in there around how could we have conversations about weight, when is that appropriate and how do we go about it, and how do we support you with this, rather than how can we get you to make these changes that we think you need to make. I think that goes really well with the attachment stuff that you were talking about as well, Kellie.

It's complex, isn't it? A lot of it is about what's happened to people. What would you say about personal responsibility? What role is there for personal responsibility in amongst all of that?

What I'd say is that I think skilled practice as a psychologist, but I think possibly for any health professional, is about being able to walk in that person's shoes, see the world as they see it, and then support them to take what action they can take, or help them to see opportunities. But in order to do that, you need to understand the person. If you're not taking the time to listen to the person and take seriously what they're telling you and think about what it means for them as a person, then they're not likely to be receptive to any suggestions that you're going to make, because you're going to be coming from here and they're over there somewhere. I think that relational approach is so important. We talk about empowerment, but I think the first step of empowerment is starting with where the person's at, and helping them to be able to step into opportunities and maybe even see opportunities that they can't see.

When I think of weight management and the social determinants of our physical health and our mental health, I think personal responsibility is a very small part of that. I think there's a lot more that we could change in our environment and in our communities and that we could support people with that would then help people feel like they can take the actions that they would like to take for their lives and have that agency and control in their lives.

If you look at behaviour change interventions, one of the most effective predictors of outcome in terms of success with making behaviour changes is social support. So if we can look more at the social aspects and where someone's starting from, I think that that's a winner, and I think it's possibly where services go wrong sometimes.

Thanks very much for that. Just the last question from me—again, you've covered this quite a lot in terms of training for health professionals, but indeed, the general public's understanding as well. Is there anything you'd like to add to what you've already told us? 

If there's not, that's okay.

I think you were quite clear on training.

I'm trying to think if there's anything I'd add to what I've said already, and I'm not sure there is.

Training needs to be meaningful, not tokenistic, and it has to be regular, doesn't it?

Maybe just an acceptance that sometimes social change takes time. This isn't something that we're going to resolve quickly, but if we don't attempt to resolve it, we won't resolve it at all.

Thank you. James Evans. 

One quick question on the complexities of obesity. I go to a fantastic gym back home and we don't have a mirror in the whole place. It's that sort of place—if you come with an ego, you're not really wanted there. It's that type of place where I go. We do know, and the evidence shows, that becoming more physically active does help with dropping weight. Do you think there should be some sort of system where people could apply to GP practices to become a trusted gym or a trusted partner, where people could go where perhaps it's a different set-up to a normal gym where I go, where you don't have people walking around in vests looking at themselves in the mirror all the time, but it's actually a more supportive environment, where people are there with a common purpose, rather than, as I said, going there just to look amazing, in a way? I'm just wondering what you think about that, whether there should be a system where GP practices could have a trusted list of people to refer people to.

I think any system that you've got for building those links is a great idea. I think the difficulty that you might struggle with is that people who are living with obesity already have their own relationships with exercise and gyms, and it might take a lot of convincing to get them through the door. However, if you can start to get some people through the door—. And I know that a lot of the work that I do involves, basically, reprogramming somebody's mindset around managing weight and how you do that. Because I know that when people do have positive experiences with physical activity or, again, they're not focusing on the weight, but they're focusing mainly on, 'I don't want it to feel like so much of a struggle when I get out of my chair', or, 'If I fall over, I want to be able to get myself up off the floor', I think if we can move towards that way of talking about exercise—and, actually, when you're managing weight, doing exercise is useful because it stops you from losing lean tissue—and, you know, having those kinds of discussions.

But, yes, I think having trusted people—. I think there are exercise providers who do understand the complexities that go with obesity, but I would say that there are far more who don't. So, I think the challenge might be, I guess, overcoming perhaps the thoughts that people who've experienced weight stigma and things like that might have about accessing something like a gym. 

I think, for me, it just speaks to, again, that idea of these very subtle but insidious ideas around health, our appearance and what we should look like. And, yes, trying to support, on a ground level, society and our communities with seeing a different way of being with our bodies, that our bodies are about what we do, they help us with our everyday lives, and appreciating those things. I think that could help reduce the fears that people have when going to places like the gym. 

Okay. I want to move on to medicines, if that's okay, because we're seeing the rise of—

I'll try my best. [Laughter.]

Yes. We are seeing a rise in people accessing over-the-counter medications to manage their weight, and they come with risks and side effects. I'm just wondering, do you think there's enough public information out there for people who do try, perhaps, the do-it-yourself version of going to Boots—?There are other pharmacies available; I sound like the BBC now. So, you go to pharmacies and buy these products, but do you think there's not enough information, perhaps, put out there about some of the risks associated with taking over-the-counter weight-loss supplements, pills or injections?

From my personal and professional experience, I feel like that there's a lot of push out there about the wonders of the drugs that we have, and less about the side effects and the kind of changes you might need to make alongside those.

And there's less emphasis on that. 

Yes. 

Jenny wanted to come in. Was it a quick question? 

I just wanted to know what possible benefit they can have unless people are being supported to change their diet. It just seems to me—[Inaudible.]—to just increase profits. 

It's like anything else. One of the questions that I asked in my job, because I've done weight management for a long time, so GLP-1s are a very, very new thing for me, and one of my questions is: how is this going to be different from another episode of weight cycling, which is losing weight and then regaining it, unless we're supporting people to change their habits? And I guess how they relate to themselves and their bodies, that probably isn't going to change, but—. Oh God. I'm sorry, I was going to say something really important and it's gone. 

Don't worry about it. Come back to it.

Write to us about it. 

Yes, I will. I'll write to you about it. 

It is around that psychological and pharmacological effect, and the holistic approach, because it is right—. Some people may think, 'It's right for me', but it's how you manage that, especially in the roles that you have, to try and say to somebody, 'Taking these things is great, but without having that psychological support to go with it, it may suppress your appetite for six weeks as you're taking it, but as soon as you stop taking it, your appetite's going to come back. And if you haven't got any changed or learned behaviours around how you treat and manage food, it's never going to be'—

I've remembered what I was going to say, actually, which is—

I'll stop speaking, so you can say it.

I was going to say, the focus, I think, particularly with the advertising of those medications—. We're talking about the fact that we need to focus on wellness; they're very much focusing on weight. And I think what's nice is that there are these messages of, 'You're struggling with your weight, it's not your fault; there are all these biological processes that are going on.' You know, 'We've got the magic bullet here.' But the focus, again, is on the weight; it's not on, 'This can actually help sometimes to turn the food noise down, so that you can make some changes that are going to benefit your health.' There's not so much of that.

One final question: do you think the Government should be harder on the regulation of how they're marketed?

I've seen recently—I don't know if you've seen, Claire—but even places that are selling patches and things like that, I'm not sure—. I have no idea—

I've seen beauty salons selling GLP-1s.

Yes. I have no idea about the evidence of that kind of stuff.

So, do you think the Government should be harder on the marketing and the availability of them? Because, as I said, if you don't have the wraparound services, it's just the pharmaceutical industry on a money-making scheme again, isn't it? I'll probably get every pharmaceutical company writing to me now, wanting to take me to court, but there we are.

I think, possibly—. I'm concerned it could be damaging. As Claire said about that weight cycling, people try their very best, and this is another thing that could help them, and then, if they find they regain afterwards because they've not had the wraparound support they might need, it could make things worse for them in the long term, and make it harder to lose weight, and affect their mental health even worse. So, even though they're a great tool—

Destroy their self-efficacy.

Yes. Even though it sounds like a fantastic tool, for sure, I think it's really important that we're a lot more thoughtful and mindful about how we use those and how they're seen in society.

In level 3 services, we would never just provide medication by itself. So, actually, why are other providers allowed to do that?

I'm going to try to get an answer, then—a 'yes' or a 'no'. So, do you think the Government should be harder on the regulating of them, and should they perhaps become more of a prescription medicine rather than something you can buy over the counter?

That's difficult then, because I guess then that would be blocking—. I would worry about blocking access, in a way, for people who would like that option.

Yes. I would say I'm probably not the best person to answer that question because I'm not an obesity physician, and I think they would be better placed. But one of the things we need to consider is accessibility. Because I certainly know that, within my service, we've only got resource to provide x amount of scripts—we can't prescribe them for everybody who would be indicated in the NICE guidelines for that.

That's fine. Okay.

If I might just add, I think it's a fantastic tool, for sure, for people who need it, but also I worry that we're focusing a lot on the medical model and the dietetic model, and not thinking about the relational model of supporting people's well-being before any of this even happens.

Lovely. Thank you very much.

Thank you, both. Can I thank both Dr Lane and Dr Turner for being with us? It's been a really helpful and fascinating session this morning. We will send you a copy of the transcript of this morning. If you think you want to add to something, or something else occurs to you, then we'd welcome any additional evidence following today's session as well. Diolch yn fawr iawn. Thank you very much.

Thank you so much for inviting us.

Yes, thank you so much.

Thank you. We'll take a 10-minute break, and back just before 11 o'clock.

Croeso, bawb. Welcome back to the Health and Social Care Committee. We continue our evidence session with regards to the prevention of ill health—obesity. We have a panel of four for the second panel this morning, and I'd be grateful if the witnesses could just introduce themselves for the record. If I start from my left.

Bore da. Good morning. My name's Jessica Williams. I'm the head of partner and service development at Sport Wales.

Morning, all. Graham Williams. I'm a director at Sport Wales.

Good morning. Bore da. I'm Fiona Reid. I'm the chief executive officer for Disability Sport Wales.

Bore da. Tom Rogers, governance and partnership director, Disability Sport Wales.

Lovely. Diolch yn fawr iawn. Thank you very much, all, for being with us today. Tell us about the link between physical activity in relation to weight loss, and other management services as well.

I'm happy to start with that. Firstly, if I may, Chair, just to say that we're delighted to be able to come and give evidence to this committee. Of course, we have submitted written evidence as well, because, from our perspective—I think I speak quite broadly, from a sport perspective and physical activity—we certainly feel that our product really contributes to the preventative health agenda of the people of Wales. We can see huge benefits and huge opportunities in terms of placing physical activity at the heart of some of these conversations. So, I welcome the opportunity to talk further, but thank you for this morning.

I think, put simply, sport, physical activity can have an enormous impact on the obesity agenda, but more broadly, health outcomes for the people of Wales. We know that people who are physically active have better health outcomes, and we also know that they're more likely to engage in other healthy lifestyle behaviours, such as limiting smoking, looking after diet, thinking about eating fruit and vegetables. So, it's a really positive tool in that sense. It's a tool that we think could be strengthened. There are opportunities to think about not only how we embed physical activity into people's day-to-day lives, so how they move around a space, how they get from work, play, et cetera, but how we encourage more opportunities to be proactive in the behaviour of, in our instance, sport, which then leads to a really positive health outcome. So, there is an intricate link. I think that there's a relationship around other healthy lifestyle behaviours. But in itself, it plays a really pivotal role as well.

And to what extent do you think the public understand what you've just said?

I think that there's a reasonable understanding around the positive benefits that being active could have on one’s life. I think one of the challenges, though, is that we need to try and think about making the healthy choice the easy choice. And actually, to that degree, thinking about how we build it into our systems so that it doesn't always have to be the conscious choice of the behaviour, but actually it's really easy to think about how you get somewhere and you're physically active en route, or how physical activity is built into some of our school systems so that children have the opportunity on a day-to-day basis to be active in and around some other things. So, I think there's a reasonable understanding, but I think we could do more, and there are certainly opportunities, which I'm sure we'll talk about over the next hour or so.

Lovely, thank you. And the panel earlier talked about there being lots of strategies in this area in terms of tackling obesity and living healthier lives, and we had a conversation about 'Healthy Weight: Healthy Wales'. To what extent do these policies and programmes and initiatives from Government—to what extent do they, in your view, incorporate the importance placed on what you said, Jessica, in terms of sport and the way sport and activity is important in these programmes? To what extent do these programmes incorporate sports and physical activity?

Chair, if I may—I think they do incorporate it. I think there's more of an opportunity to think about what we are saying through those strategies and raising the profile of what sport and physical activity can do from a public health perspective. And if I just use some words that the World Health Organization said back in 2022:

'There are few areas in public health—such as physical activity—where evidence on required action is so convincing, cost effective and practical.'

And I think that sets the tone of perhaps where we need to be thinking about physical activity. I think we need to set a new ambition around physical activity. And to your earlier point, we need a new language, because talking to members of the public about 30 minutes of moderate-intensity physical activity every day perhaps doesn't engage.

It doesn't engage.

It doesn't engage, but 'Sit less, move more, enjoy your walk with your friends'—we've got to think of a different narrative that describes what not just the physical benefits of being active can bring, but the much more wider mental, social and potentially environmental benefits as well. So, I think we need to reframe it.

But going back to your original question, I think there is a good start in those strategies. Inevitably, physical activity probably doesn't get afforded the priority that perhaps it needs to be, and I think that's why I use that quote from the World Health Organization about it seems to be a real opportunity to make a step change. And I think a country of our size, actually, and our ambition—we can do that.

Okay, and Fiona, have you got any comments from your perspective in terms of my two questions?

Yes. I think I agree and completely support Jess and Graham's perspective, but I think, from a disabled person's perspective, it's ensuring that it's much more explicit about population-level action so that where we do connect up the policies and the starting points that we're all coming from, we can see it very clearly how everybody can engage. A lot of the work that we do really highlights the value of physical activity as part of the pathway into sport, but may not have sport as its only or ultimate destination. So, for us, it's just making sure that there's that differentiation by community and population, because we know that where physical activity and sport are both concerned, there's a significant gap still in participation, opportunity, accessibility. So, yes, we'd like to see that gaining slightly greater priority through policy.

Joyce, and then I'll come to you, Tom, if you want to come in as well. Joyce. 

Just on some of that opportunity for disabled people—the first opportunity most children have to engage in activity is either through school or the local play area. And the local play area is, very often, not built with disability in mind. So, the question I’m going to ask you is this: when we’re looking at—. Or is there any evidence that, when local authorities or whoever are going to build a new play area, they actually have to, within their plans and their agreed formulas for funding them, pay attention to making it fully accessible for all?

I think there’s definitely a greater move towards that. Whether that’s mandated—I’m not familiar enough with local planning policy to be able to answer your question fully. But, certainly, our observations would be that where green spaces, blue spaces are—primarily in your question—accessed by children, but also by adults who might acquire an impairment later on in life, we can do better to ensure that there is good accessibility, and that we communicate that accessibility as well to disabled people within our communities, so that they do get the opportunity to play and engage with the environment that we’re so lucky to have in Wales.

Tom, did you want to come in?

Can I just add a bit on that, especially around—? Sometimes, we forget to communicate what is available to disabled people. So, in some cases, there might be excellent facilities out there, and there might be some that are not as good, but because disabled people are probably used to some of these facilities—whether that’s a leisure centre, or whether that’s a play area—not being for them, they might not go and explore and say, ‘I’ll go out and try it today.’ So, it’s around how we can explicitly go out and give them as much information about what’s available in an area, and they can make that informed choice, as that disabled person, of what is available to them as well. So, sometimes, there are easy wins and sometimes there are bigger wins around influencing any new builds. That’s 100 per cent the way we need to go.

Thank you. Jenny Rathbone. 

Thank you. It was good to hear Jessica speak enthusiastically about 'Healthy Weight: Healthy Wales'. I just wonder if you could tell us how it has changed the relationship that you have with other weight management services, because it’s quite a holistic field.

I think 'Healthy Weight: Healthy Wales' has certainly given us a platform to work in a really collaborative, cross-sector, cross-policy area way. And I think, as a strategy, it’s a really good vehicle to start to talk about some of the things that we think would be important in terms of how we embed physical activity into people’s lives. And what I mean by that is that there are conversations with colleagues at a Welsh Government level who work in the health policy division. Similarly, within education and planning. So, I think it’s a really good platform for that. We might come on at some point in the next hour or so into the opportunities we can build on from that platform. In terms of weight—

I'd like to come on to them now, actually. What impact is it having on the ground?

In terms of weight management, I think, from a sport perspective, everything that we do is geared up towards preventative health. So, we, as organisations, are kind of enablers of people who deliver on the ground. And inevitably, what we deliver in terms of sport, physical activity, will contribute to positive weight management for individuals. We don’t work directly with services, such as weight management services, but we certainly collaborate in a health policy area.

In terms of the opportunities going forward, I think strengthening the elements around physical activity within those strategies, as Graham mentioned earlier, would be a real positive for Wales. And I think we’re a small enough country that, actually, we can work collaboratively when those areas are strengthened. I think it's about prioritising young people—the question just before around the environments that young people are in—so that we do set young people up for success, and we set them up to think about healthy lifestyle behaviours for the rest of their lives. That includes physical activity. That includes thinking about healthy lifestyle choices around food, drink et cetera. And then we also think about how much allocation is given around preventative health measures in terms of budget opportunities and budget lines. And I’m sure that’s a wider conversation around the positives around a preventative budget line, but also thinking really long term in terms of how we budget in that sort of space.

I’m sure that those who are making a success of sport are given lots of important advice about food and drink, but what conversations do you have with all of the grass-roots sports organisations that are represented through you? How do we counter when a person does all of this sport and then they revert back to the so-called energy drinks, the crisps and all of the other things that are actually killing them?

Like I said, as an enabler, we work with a range of organisations that will do our delivery. There are a number of specific examples. One in particular is a children and families project, and that sits within the health division and is shared as a pilot project with sport. As part of that, there’s an active arm. So, we work with three pilot organisations in terms of physical activity for a family network—so children and their families—but there’s also a nutritional arm, and that’s co-ordinated by Public Health Wales. So, there’s real collaboration there in the opportunity that somebody who is part of that pilot is getting. That pilot is called Children and Families. We’ve called our arm Pipyn Active and there’s also a Pipyn nutrition arm. It’s very much in the pilot phase at the moment, but the conversation about how this can be rolled out nationally and how can we think long-term about this as a programme—certainly, those are positive conversations.

I think in terms of, perhaps, more on a grass-roots or sport delivery perspective, I’m sure that there would be conversations happening within local sports teams, clubs et cetera. I’m perhaps not close enough to some of those clubs to be able to articulate those, but referencing my earlier point, we know that there’s a relationship between people who are physically active and then people who engage in other healthy lifestyle behaviour choices. And we see that in the national survey for Wales, we see data that proves that people who are active more than three times a week are more likely to think about other healthy lifestyle behaviours. So, there’s certainly a relationship there.

Jenny, are you happy if I bring Joyce and Mabon in here?

Yes, go ahead.

Joyce.

Five minutes ago, I had an e-mail—we’ve all had it, but I picked it up—from grass-roots sports needing additional backing because of the financial situation that they’re finding themselves in, particularly when it comes to community hubs. This has come from Sported. And that research that they’ve just launched found that 67 per cent of clubs and groups believe that they aren’t getting the investment into that grass-roots sport to back its important community-level engagement. But more worryingly, that survey finds that 50 per cent confirm that young people in their group disengaged from or reduced participation in sport and physical activity over the past six months because they can’t any longer afford it. And 53 per cent of those said that travel was cited as the major factor, and the affordability of those facilities, maintenance and limited space, particularly those who own their own facilities. So, what I’d be interested to hear, because that is of concern—this is a Wales survey, by the way—is how do you help to engage those in your role, particularly in light of that report?

As this is Jenny’s section, can I take Mabon’s question as well? I’ll ask the panel and then come back to Jenny. Mabon.

Just briefly, Jess, you mentioned there budgets and the importance of preventative measures. We heard recently that some local authorities are now looking to cut leisure centres because of the settlement from the Government, and we’ve seen leisure centres being closed over the last few years because of financial difficulties. If local authorities were to cut leisure centres, how do you think that would impact on people’s health? And will that impact the obesity levels in Wales and the preventative agenda that we are trying to develop?

Do you want me to—?

Yes, please go.

Chair, if I can, maybe, just respond to the first point in terms of Sported. So, a couple of observations, if I may. One is that we do, as a national agency, fund Sported so that they can do that type of research and evidence base that you were referring to. So, we do directly fund Sported. It is challenging. So, the findings of that are pretty stark, aren’t they? We are facing that cost-of-living challenge. We’ve had our own budgets reduced. Most of our budget goes out to partner organisations to deliver because we don’t deliver ourselves. And those challenges will remain. We do have schemes available that support local community clubs, and we do put a greater emphasis on those that are, perhaps, from our poorer parts of society. So, we put a great relevance in terms of grant funding towards those. But we can't deny that that is a challenge as we move forward. Our budget was £2.5 million less last year—a 10.5 per cent reduction. We managed to ensure that lots of that wasn't passed on to the sector, but it inevitably does impact on that sector and I think that's one of our biggest challenges.

And I think—going to the second question, which is about leisure centres and cost-of-living pressures—that if we frame leisure centres as an activity and a wellness hub, then I think that's how we need to be promoting them to show their full value to the communities in which they're based. If they are viewed potentially as a swimming pool that costs a lot of money to heat and treat and staff, and it's difficult to access, then, I'm not surprised that, maybe, they are areas of services that are not core to what local government deliver and that, under budget pressures, undoubtedly will face challenges. But I think, in the way that we're trying to frame how sport and activity can help the health and well-being of Wales, we need to start looking through the lenses of facilities and local service delivery also through that same lens, which is about how they contribute to the health and well-being of Wales? I don't think it answers your question directly about what is its impact. Inevitably, it will have a community impact and we would hope that there are lots of equality impact assessments, local community assessments, that would take place before we reached a point of closure, but unless we see them as a contributor to the wider health and well-being of Wales, it becomes really challenging.

Okay. Jenny.

I'll come back to facilities in a moment. I just wanted to follow up very briefly with Jessica. You said you were having some useful conversations around the child and children and families work stream. At the moment, it's still a conversation going on with Public Health Wales—it's not something that's had any impact on communities I represent—

At the moment, we're in the second phase of a pilot of three years with that programme, so the conversation is about how we continue that beyond the pilot phase, because we are seeing some really positive impacts. 

Okay, so we'll look forward to hearing about the impact there.

I just want to turn now to people with disabilities and how we enable them to have sport. And starting with people with physical disabilities, it should be, in most cases, rather obvious to everybody, including the local GP and health visitor, that this individual is going to need extra support and attention to the importance of physical activity. Obviously, we've got the Paralympic movement, which tells you that anybody can do sport, but, just at the grass-roots level, what conversations go on with the people working in the community in health about how they encourage people with disabilities to do sport, and, obviously, that needs to include feeling welcome in whatever facilities are available?

Can I hand over to Tom?

Hopefully, we have a programme or a partnership that can answer some of this. So, there's a health disability activity pathway, which is funded by the Welsh Government, into health boards. So, within each of the seven health boards, there is a practitioner whose role it is to train health professionals in those areas to get the secondary—a physiotherapist, or an occupational therapist or a GP et cetera—to signpost people who they see day to day, as their patient or whoever they're working with, into community settings. So, essentially, not at the Paralympic level, but into those grass-roots examples. That relies on partners across Wales. So, they don't come into Disability Sport Wales or Sport Wales; they go to a local authority or the equivalent, so, like a Newport Live or Met Sport in Cardiff. So, they get signposted to there to find the best opportunities for them. So, that might be a specific session—. Sorry, you started with physical impediment, but this is across every impairment group.

Then the secondary part relies on partners within national governing bodies, or those local authorities or the equivalent again, through insport club, which is a mechanism to support clubs to offer that welcome environment—so, a toolkit to help them to provide that in the best way. So, there are 340 of those nationally. They're in every area of Wales. And the secondary benefits are, when we talk about transport and facilities, that the highest number of those clubs, which I think we're seeing across Wales, would be in some rural areas. So, in Powys or Pembrokeshire, it's particularly high, and then that does transfer across a lot of those rural areas where we, maybe, rely on those clubs to provide those well-being places, where it's easier for them to offer that equitable approach, and, about the leisure centre point, that would have that secondary impact on the transport element, because our transport network is aligned to those as well.

So, the individual in the health board is the champion for ensuring that facilities are accessible—in the broadest sense, not just physically accessible—but also for laying-on sessions for people who are never going to be at the Paralympics but just want to have some fun and some exercise?

One hundred per cent, and the easiest way to align—. So, there will be someone in Aneurin Bevan health board that's aligned, in Gwent, to support the training of those health professionals and then they will liaise with the five local authority areas in that health board region. So, for example, in Newport, that would be someone called Tom Hole, who is in Newport Live's team. He will receive the signposts, and then allocate, so he'd be the champion for what's available in that area. The health board representative is the champion to support those health professionals to align the two sectors up, if you like.

Okay. So, how engaged are GP services in ensuring that they're using social prescribing to do some sport, even if it's just going for a walk? It very much depends on the individual's ability, but it's the GP or the pharmacy that is going to see somebody who is not feeling well mentally maybe. How do we ensure that everybody's thinking that physical activity is part of the solution?

Can I—

I was just going to say—sorry, the last point from me, and then I'll pass to Fi—as you said, it depends on the individual, as in the individual coming in. I think a lot of it depends on the individual that they meet, how much time they have and where they sit in the setting. You asked specifically about GPs, but we see the vast majority, a really high percentage, of the signposted people come through physiotherapy or occupational therapy. They are much higher than the others. GPs depend on engagement. In some areas, in Betsi Cadwaladr, for example, it's been established for three years—the pilot that happened in Betsi. They're much more engaged there, but, for GPs, sometimes, it's much harder to get into the training slots with those professions than it is, maybe, for some of the others. Fiona.

Yes, I was just going to reinforce that the purpose of the programme is really to kind of connect with health practitioners to raise their awareness, because, originally, it came from a pilot project funded by Sport Wales in Betsi Cadwaladr University Health Board, and the review that we started with was around awareness of opportunity for physical activity for disabled people across the spectrum of impairment profiles, and it was relatively low in terms of awareness. So, if that every contact counts with a health practitioner, but they're not one that is familiar enough with the physical activity environment, then it's unlikely that they'll be signposted; the expectation will be, 'Well, there is no physical activity opportunity for this individual.'

So, that's the whole purpose, and I think, across Wales, the connectivity into different areas of health with different health practitioners, as Tom said, just depends on availability and priority and the frequency with which they're seeing disabled people so that the training can be focused.

So, what about people with learning difficulties, because I don't know whether they get to see occupational health or physios?

There is a good example of that, actually, on Ynys Môn, wasn't there, in terms of the relationship between the health practitioner and social services, and there was quite a high volume of people with intellectual impairment, learning disability, who were then signposted into their local leisure centre to be able to access physical activity opportunities that they knew were inclusive. So, yes, it's present there as well, so it's connected, but that's not to say it couldn't be better.

Okay. And lastly, the committee's heard loud and clear the connection between mental health and obesity. So, what connection do you have with mental health services to ensure that they're using the referral pathway to physical activity to help people cope with that issue?

Again, that would predominantly come through the health disability activity partnership with the health boards and the practitioners within those health boards. I think, for disabled people, that the impact on mental health over the past few years and the benefit that physical activity can have on life satisfaction are significant, so it becomes really important that we do connect up the opportunities for physical activity as part of the solution to enhancing our life satisfaction and starting to address some of the elements of poor mental health.

Okay.

Thank you. James Evans.

Diolch, Cadeirydd. I'd best declare an interest, because Sport Wales fund an organisation that I'm a committee member of, so I thought I'd put that on the record. I just wanted to say, before I start, congratulations, as well, on signing the armed forces covenant from Sport Wales. I think it's a really positive step and something I pushed the Minister on quite heavily, so I'm quite pleased he's done that.

I want to ask about the activity levels of adults engaged in sport, because, in October last year, the Wales activity tracker survey that Sport Wales run reported a drop of 14 per cent of adults who are actually engaged in sport and physical activity. I'm just interested in what you think the reason for that is and what specific measures Sport Wales are putting in place with the Welsh Government to try and drive more people back into sport and physical activity. Whoever wants to go first—. Jessica.

So, the Wales activity tracker is something that we introduced during the pandemic, and the purpose of that was to look at, almost, if you like, seasonal trends in terms of periodic times in the year when activity levels may change because of certain things. One of those things might be adverse weather, for example, and another thing might be the cost-of-living crisis. So, it's a really nice touchpoint for us in terms of monitoring activity levels and thinking about what are the ebbs and flows. I think there's a range of factors, and I don't have all of the statistics to hand, but, certainly, there have been a number of barriers mentioned, around costs, around accessibility, around the offer that's to hand, seasonal changes—if you're going into a winter month—and there are gender differences around being comfortable exercising outside, et cetera.

We have a number of ways in which we encourage people back into sport, or, I suppose, to participate in sport. We've mentioned some of our partners that do deliver, but we also operate a community investment stream. So, we've got a stream called the Be Active Wales fund, and we fund organisations, clubs, et cetera, to really look at how they can do things differently, but deliver at a real grass-roots level. There's a number of really creative examples that have come through that—basketball clubs that have used neon-lighted vests, because people don't like to be seen exercising out in the open, so they do it in a darker room. We've had all kinds of examples of equipment that can be placed in different facilities that suit individuals. So, I guess, one of the ways in which we work is to think about what is the sporting offer that can be the most inclusive, accessible, fun, enjoyable thing possible. How do we think creatively about some of the opportunities that we have to support that, because we know that that helps people come back to sport and make that part of their lifelong habits? Sorry, you were going to—

Yes, maybe just three examples of some of the things that we've practically done to try and improve activity levels: firstly, we've changed our approach to investment, so our investment now targets those that are less likely to participate, so, in all our networks, we're widening and broadening our network of partners so we can ensure people feel more supported in their local communities, and we're starting to see some impact of that. We've also established what we've called sport partnerships across five regional areas of Wales, where they bring together a wide range of stakeholders that really look at their communities and how they can better support. It's difficult sometimes being the national agency when we're not close enough to the communities that really need the support, and, therefore, we've put a mechanism in place.

And then, really quickly, finally, we are doing some proactive work with some other national organisations, with Public Health Wales being one. We believe that part of the issue around physical activity levels more broadly is about the need to focus on young people and normalising physical activity as a behaviour—it's a normal part of what children and young people do—and we are working closely with Public Health Wales and others like Natural Resources Wales and the health team in local government to look at a whole-school approach, so how you get to school, what you do when you're there, what you do in breaks, how you can make active lessons, what you do after school, what you can do with family and community. And we've got some really interesting proposals that we're hoping to take forward, but unfortunately, at the moment, we're not able to take them forward for some of the budget pressures that are there, but nonetheless, there are real examples of where we're trying to work in partnership at a system level to try and really tackle what we know have been very persistent and stubborn inactivity levels over a very, very long period of time.

Because that same survey highlighted that 70 per cent of people classed sport and physical activity as a key part of their lives—keeping moving and keeping physically active, stopping the obesity trend and stopping people becoming inactive. How do you use that to leverage Government in terms of budgetary decisions, then, and people like Public Health Wales, for example? Because tackling inactivity is a whole-Government approach, isn't it—it cuts across education, public health, health boards and local government as well. So, I was interested in how you leverage Government for funding. I know that your funding has been cut, but considering that a big proportion of the responders said that sport and physical activity is a key part of their lives and tackling obesity through the 'Healthy Weight: Healthy Wales' strategy is a key driver for Government—. I'm just interested in how you use that data to try and lobby Government for more funding. Obviously, it hasn't worked to date, but I'm interested in how you use it to do that.

There's a range of mechanisms in place that allows us to do that, from discussions with our Minister, through inquiries in other committees. There's a recent one through the culture committee that's just reported on funding levels for sport and physical activity and wider culture and arts and how, perhaps, that's relatively low in comparison to other European counterparts, and there are some recommendations there. There was a recommendation, or some commentary from Government—not a recommendation, sorry—some commentary from Government about how sport could be the greatest preventative health tool. We've done a number of engagement sessions across Senedd Members and Government to try and make that case.

I think part of our role is that we know sport for sport is really, really important, but we're trying to communicate sport's role in its wider sense in terms of what this committee is interested in from an obesity perspective, but, more broadly, the health and well-being of the people of Wales. And we feel that it is one of the tools that probably hasn't been deployed to its maximum at a time when there are lots of budget pressures and increasing demand on ill health within health services. And therefore, it's probably one of the few interventions—the Chief Medical Officer for Wales said that if it was a drug, it would be a miracle drug. How do we translate that into practical action? I think the reality is that that is work in progress; we haven't achieved where we want to get to, but we are working in partnership. We advocate that through our contributions to the 'Healthy Weight: Healthy Wales' strategy and those wider engagements that I just referred to.

Do you think Government silos don't help? Because your funding primarily—well, most of it—comes from the culture department within Welsh Government, even from the disabled side, it all comes from the culture department, but a lot of what goes on in the disability element of it is in the social justice department, which sits under Jane Hutt. And then you've got Jeremy Miles's department on health. Those funding pots don't seem to help. With it going into the culture department, no-one looks at that holistic approach across Government of budget setting. I'm just interested, do you think that the siloed effect that we have in Government, the departmental silos, stops that funding coming through to you? And basically, the culture budget is one of the smallest in the Welsh Government, when actually, as you said the chief medical officer said, sport and physical activity, if it was a drug, it would be a wonder drug? Do you think the Government's set-up is a problem in delivering some of the aims the Government want?

It can be a challenge. I'd probably just reframe it slightly. I think if physical activity was everyone's business across all departments of Government, that gives a mandate to start thinking about it, because I suspect that, in most cases, it is an area of relative interest, but it's probably not the most important area of interest, and other priorities take precedent. I do think that the notion of a cross-governmental approach to physical activity is one that's supported. I think, inevitably, the structures can work if there’s a mandate that sits behind it, and I think it’s that work to get the mandate around, ‘Make this everybody’s business.’

It links back to my final point about 45 per cent of people as well stated cost around barriers to sport. If you look at the cross-departmental working, that probably is a barrier as well, isn’t it? I know another colleague will probably pick up on the children’s side of it, whether that’s in education or the disability side of it and the social justice element. The funding doesn’t seem to come through to address the barriers; it’s all being pulled out of one little pot, isn’t it? Is that something that worries you as well, that actually those people who can’t afford it aren’t being supported by other Government departments to enable people to take up these activities that we want them to?

Does somebody else want to come in on that?

I would say that there’s more opportunity to connect, exactly as Graham said. I don’t feel I’m best placed to identify whether it’s because of silos or not. I think it’s because we need to ensure that, as Graham said, physical activity is everybody’s business, and making sure that every community can see physical activity as part of their lives is really important. I think the opportunity to connect—. And what we’re not asking for is to take some budget from somewhere else to bring it into sport and physical activity, what we’re asking for is to take the lessons that we’re all generating around physical activity, and sport in some cases, and apply them across all of our areas of work and priority.

Can—

Sorry, Chair—

Really quickly, then.

Yes, it’s really quick, and it’s on the disability element of it. Do you think enough is done by the broader organisations? I’m going to pick a few, say the Welsh Rugby Union, the Football Association of Wales, some of the organisations funded to deliver some of the projects around disability—do you think they do enough in that space to try and improve access to sport at a grass-roots level? In a way, do you think enough is coming through the system to actually enable people to try different sports? For example, as I said earlier, a golf club that I was heavily involved with—

Just a short answer on that.

—was heavily involved in doing it, and the funding got cut.

Fiona.

I think there is a growing appetite to do more. The programme that Tom referenced earlier, insport, is how we see our role in creating inclusive cultural change within those national governing bodies. There are some really, really good examples of real thought around how they provide for disabled communities and how they differentiate the offer at grass roots through to touching on and up into performance. But there are a number who probably could give a little more focus to it. That’s how we see our role, alongside Sport Wales, to support that change.

If it's really short, Joyce, like 10 seconds.

It is short, very short. Neurodiversity training in sport—what people regard as a hidden disability, but nonetheless it's prevalent.

We provide free access to training, and we work in conjunction with Neurodivergence Wales to provide that course.

Yes, there is training for it. We offer a learning series that goes to the sector. On James’s question around the NGBs, there are 28 that work on our insport programme, so they would then access that training, and there are 10 partners, which would include the Urdd and stuff that is quite engaged within physical activity delivery. Then secondary, around the insport programme, where we support and work directly with local authorities, Pembrokeshire, which I know is your local area, have achieved gold standard in that, which included neurodiverse training across the whole local authority. We helped influence and support the development of that for all staff, not just for physical activity, sport delivery or leisure, but the whole local authority.

John Griffiths.

Diolch, Cadeirydd. Turning to children and young people specifically, you've already said—it's obvious, I guess, isn't it—that if you can get good habits established early on in life in terms of taking part in sport, being physically active, then that's going to be very good for those young people throughout their life courses and will inevitably help tackle issues around obesity. So, I just wonder, what are the latest trends? Can you tell us whether we're moving in the right direction or not in terms of participation by children and young people, and, of course, children and young people with disabilities?

Perhaps if I start, Chair, in terms of the wider picture. I think this is a stubborn long-standing issue. Overall activity levels in young people haven't really changed for many, many years. I think we know, and the committee may have heard, that one in four children are entering school either overweight or obese. One in eight teenage girls do enough activity to gain a health benefit. They're pretty stark statistics, aren't they?

I go back to my earlier point about the need to normalise activity, so that it's just seen as a natural part of what you do as part of your growing up. And the school environment—without, importantly, putting additional pressures on schoolteachers and school staff, and I think that's a really important point to make—provides us with an opportunity to provide equality of access for all, and as I said earlier, we're working with other national agencies around this whole-school approach. It's one of the identified areas, through the World Health Organization's global action plan on physical activity. A whole-school approach is one of the best buys and interventions, and we feel there's a real opportunity. We've learnt from international best practice: Finland's got Schools on the Move; there are initiatives taking place in New Zealand—Healthy Active Learning. We feel that there's a real opportunity to try and make a step change in terms of activity levels, but it needs the infrastructure and funding to make sure that that happens. Fi, I'll maybe pass to you in terms of some of the participation challenges for young disabled people.

We know that there's a gap in terms of—. There's a difference in activity levels between disabled and non-disabled children. We know that children aged two to 15 are 35 per cent more likely to be obese if they have a limiting long-term impairment. So, there's much greater risk. From our perspective, we're giving a commentary about the value of physical activity, and if school is where it starts and where you gain your aspiration to be physically active, unless that environment physically welcomes you as a disabled child to physical activity, you are then much less likely to go into activity outside.

We know that the challenges and barriers that non-disabled children face within a physical activity environment are accentuated for disabled children. So, just taking as an example transport at the end of the school day: often, children are very dependent on taxis or transport services that are quite rigid in terms of their provision, so that makes after-school activity much harder to access. And to go back to your earlier point, Joyce, just around the accessibility of green spaces and play spaces, we need to make sure we attend to that as well within the school environment. So, there are lots of things at that early stage where we know there's a gap between disabled and non-disabled children's activity, and it's not just the school environment, it's outside the school environment as well. That's where that connectivity across portfolios becomes really, really important.

Okay. Thanks for that. Could you point us as a committee to policies and programmes that are effective in teaching children and young people the importance of being active and taking part in sport, which would actually do a lot to encourage them to take part? Is there any particular improvement that you'd like to flag up to the committee that needs to happen?

I'd probably just go back to what I said earlier, really. I think the recognised best buy at World Health Organization level is a whole-school approach to physical activity to support all young people. It's important that that's done in a way in Wales that doesn't place a burden on school staff, and we are working with our health colleagues in Government, Public Health Wales and Natural Resources Wales to try and initiate it. I think the challenge, John, has been the budget pressures and other areas taking an immediate priority. We're still very, very supportive of that approach and believe it will have, in line with the Well-being of Future Generations (Wales) Act 2015, a very long-term approach focusing on prevention and better health and better activity. It would have a huge impact on people of Wales if we were able to drive that work forward.

So, there is good evidence, both within Wales and there is good evidence internationally, of what we need to do. I think we're really clear about what we need to do. It's finding the wherewithal with which to do that that has become, I suppose, the challenge.

And if I may just add to that, internationally there are some really good examples of where, in particular, the school environment, the school setting, has been used as the vehicle to encourage children to be active at a whole-school level—so, not just what happens within school, but travel, et cetera, extracurricular activities. One example—I'm more than happy to send the committee some supplementary evidence—is in New Zealand. There's a programme called healthy active learning where there's been a collaborative effort between the health sector, the education sector and the sports sector, and a shared budget portfolio there, so there are no additional pressures on any one portfolio. But the idea is that that setting is really harnessed for this idea of a whole-school approach that translates into young people's experiences, but also a wider wraparound into family experiences. Some of the challenges that we see about non-communicable disease, such as obesity in Wales, are no different to some of these other countries. And I think there's some really good best practice learning there, and we're certainly modelling some of what we would like to do here on that.

Thanks for that. Please do send it to us. I think New Zealand is such an example of excellence in many sports, including rugby, of course. And it's not just about the elite level, but having a more active population feeds into that, doesn't it? There you are; if we can adopt some of their approaches, we might find the Welsh rugby team performing better, who knows?

I think John's angling for a committee visit to New Zealand. [Laughter.]

Could I just ask? In terms of the importance of school, Welsh Government wants to make many more schools more community focused, and that's been a long-running aim that's been frustratingly difficult to achieve in practice, I think. But it's got a renewed commitment, I think, now to making more schools community focused. We've got the new curriculum. So, where do you think we are at the moment with schools in terms of how active our children are during the school day—children generally and children with disabilities? What's the current picture, would you say?

I guess, with many things, possibly quite mixed. I think one of the things that is currently live in terms of our work is how we can support teachers through the new curriculum, and particularly the health and well-being area of learning and experience, so that they have the right confidence to think about physical activity as a really important factor across the school day—sitting less, moving more, opportunities for active lessons. I think there's an awful lot that goes on around the break times and, in many schools, pre and post. I think, to your point, John, it's probably a patchwork in terms of community use, and I think we need to think about how those facilities are community assets in one sense and can be opened up when it's appropriate to do so. But the work that we are trying to move forward is—. It's the key actors, isn't it, in those spaces—teachers and learning assistants—they will enable those young people, they have the opportunity to build it into that environment. But it's important that they feel they've got the skills and confidence, particularly in a primary setting, actually, to be able to do that, and we hope to be able to support the curriculum.

And it's important, isn't it, in terms of talking about physical activity here, that it's seen as a contributor to education outcomes. It's not just physical activity in its own right. Physically active pupils, they're more engaged, they're more likely to attend, they're more resilient, and therefore we need to be good at explaining the education outcomes that can come forward as a result of young people being more active in the school environment.

Thank you. Did you want to come in quickly, James?

Just on this point, do you actually think, though, that the regulatory regime that we have in Wales goes against some of the things that, actually, I'd like to see more—sport and physical activity in school? I've seen the schemes in New Zealand, and the Falkland islands, actually, are doing exactly the same thing, mirroring New Zealand. But the regulatory regime we tend to have in Wales is focused on English, maths, sciences. It doesn't really focus heavily on the sport, and it's more about academic performance rather than what sort of pupil is coming out of the school at the end. I went to school with somebody who wasn't very academically sound, but went on to play for Wales and is very successful. So, do you think sometimes, as I said—back to the original question—that the regulatory regime we have puts more pressure on schools to push more the academic model of pupils, rather than giving that, perhaps, holistic approach to introducing them to more sport, which, as you said, has been found to make, actually, pupils, like it did in New Zealand, more active and actually interested in sport? It actually helps neurodiverse children as well, as Joyce mentioned earlier, to focus the mind a little bit more and give them something to focus on. Just your thoughts on that. 

I'll just take Jenny's question as well. We are a bit tight for time, but I'll just ask for short responses to the two. Jenny. 

Okay. I just wanted to focus on something that was raised in a previous session by Professor Haboubi, who's based in Blaenau Gwent, the capital of obesity, and he pointed out that the best five counties for body mass index were in London, and that was because it's impossible to commute to work in a car in London; it's punitively expensive, so people don't do it. So, I just wondered what we do to turn around this terrible label that Blaenau Gwent's got for being the capital of obesity, and what role you play in changing the culture around active travel, both walking to primary school and then getting the bike out for secondary school, because it's further away. 

So, they're both quite big questions but, if you could be as brief as possible, because I've got Joyce who's leading another section and then Mabon to come in on some other questions as well. Who would like to respond to either of James's or Jenny's questions? 

I would love to see physical education being a statutory component of the school day. I think that that would be a real step forward and probably would help engage activity in a different way. But I think the real benefit of the new Welsh curriculum is that it doesn't just focus on sport, so it's not just about playing football or playing rugby or playing netball or playing hockey; it's about how you move and how you can then apply that into a lifelong engagement and enjoyment of sport. And I think what, additionally, I would like to see is that that is also more inclusive of disabled children and young people within the school environment, so that they also get the same exposure to the likes of boccia and wheelchair basketball, goalball, so that we raise people's expectations around what's possible. Sorry, Graham. 

I'm not sure I can answer it in the time we've got available, but I think there are certain areas that we could focus on. I talked earlier about a different narrative about how we engage communities and individuals in activity. We need to talk about sitting less, moving more, the environment in which you're able to do that. Do you feel safe? Is it lit? Is the footpath appropriate? So, we need people to be thinking about the environment, and that's why I think it needs to be everybody's business. So, from a planning perspective, I think from a health and social care perspective, from every contact with GPs, about encouragement, it lends itself—and I know it's a term that's used quite often—to this 'whole of system approach', to be thinking about how do we normalise and make it possible that activity is the easy choice, not the hard choice. It probably needs unpacking a lot more than the time we've got today, but I think they're some of the areas that I would focus on. 

Thank you. Joyce Watson. Oh, sorry, Tom. 

So, James mentioned the Falkland Islands earlier, and I'm involved with Ynys Môn island games, and Åland islands, which is Finnish, speaks Swedish, between the two, prioritise being able to make that the easy choice of travel. So, if they're building something new or developing something, there is a way to cycle there or to push a wheelchair or to walk. That's always a priority in any planning. That's the cross-department stuff, not taking the budget off them. And I think it was either Jess or Graham that said initially around being ambitious, and, Wales being small, that you can be that ambitious. So, an island can obviously do that, because they're even smaller, and London can do that because it's condensed, but Wales could probably do that to a certain extent as well, about being ambitious, being creative and using being a bit smaller as a benefit. 

I'm sorry to rush this section. We can perhaps take some other written evidence, if you're willing to, in terms of some of the points that Jenny's raised. Joyce, if I can ask you to ask your questions in about five minutes. I want to allow 10 minutes for Mabon at the end of the session. Joyce. 

I'm going to. I'm going to give another example, and I'm just leaving it on the table. I was in Norway last summer, and, from the very first time that young people are able to go outside, they go outside, regardless of the weather. It's all to do with the short days, of course, because it's getting them ready for that—for the cold, for the wet, for the lack of light. So, I'm just leaving that on the table. What I really want to know is how you convince people to become active who have negative thoughts about that, for whatever reason, who have an attitude that challenges them to think about it being a positive. We've heard—. Of course, this morning, this is in relation to obesity, so part of that will be body image and how they look.

Shall I just reinforce that, and then I'll give it to you, Jess? So, attitudinal barriers, whether that's individual parents, coaches, providers, are huge within disability and inclusive sport. There's a massive barrier around presuming something's not for you or, 'I won't be able to do that.' That first step is really hard. What we'll find, in most impairment groups, but, especially within learning disability particularly, is that, once they've built that, you've put that extra work in at the start, they're incredibly loyal to that activity, that provider, because they now know, 'That's for me and that's provided', and they will stay in that activity for life. So, you get that lifelong enjoyment, that lifelong participation, if you just put in that equitable patch from the start. So, it's really important, and it does create a bigger barrier for disabled people in that. I'll pass to Jess, because I don't think I answered your question—I just agreed with the question.

I agree with you, Tom. So, I think there are four things that come to mind in terms of how do you do that convincing piece. So, firstly, we think it's about the quality of experience. So, if somebody has an experience that is fun, it's developmental, it's safe, they're more likely to come back to that, because they've had a good time, which is exactly what Tom has described. Making it easy for people: so, making the healthy choice the easy choice and normalising it, so it doesn't feel like it's an additional burden to somebody's life. Providing opportunities that are accessible. Tom articulated that really well, but that is going to take a real person-centred approach—so, thinking about the needs of a group, of a community, or the needs of a certain individual, and thinking about how things can be adapted. And there's also some really good evidence. So, the Wales Centre for Public Policy put out a really good evidence report in 2022, I think it was, which looked at healthy lifestyle behaviours. And there was a suggestion there that, actually, talking about fun, enjoyment, experience, rather than, 'Do exercise, play sport, physical activity et cetera, because of your weight', actually that flip side of thinking about, 'Do more of it, it's really good for you, and you'll have a good time', is exactly how we need to start to talk about that from a language perspective. So, I think four things really come to mind around how we can shift that mindset into thinking about, 'This is a real opportunity' for the population.

Can I give just a practical example of that, through the Get Out Get Active programme? That was a programme that was intended to engage the least active of the inactive—disabled and non-disabled people—active together, and intersectionally. So, there was a great example in north Wales, with LGBTQ+ disabled communities, where their activity was by stealth. So, it was stuff that they were doing anyway; they didn't necessarily recognise that, when they went shopping, they walked or moved 5 km. So, it's about just alerting them to what they are doing, and encouraging them to keep doing that and just do a little more of that, whilst looking for other opportunities as well.

Since this is particularly about trying to get people active, linked into obesity, what particular or specific actions are any of you taking or do you know of that are encouraging that group of people?

It will have to be just one person responding to this, just briefly, if that's okay.

Shall I take it? I think, from our perspective, the drive for physical activity is not anti-obesity or to prevent obesity. The drive for us to do what we do is to encourage more people to be active, which as a consequence has a link to, has a relationship with, obesity, and greater levels of activity, potentially, would impact on lower levels of weight gain. So, the driver is slightly different for us, but, obviously, with disabled people, there may be a higher incidence of obesity. Certainly, for those people who are living with obesity, they may acquire impairment or a disability later in life, or as a consequence of gaining weight. So, I think, for us, it's much more about identifying programmes that focus on activity and finding something that you can access, and supporting organisations to provide opportunities that are accessible. The Get Out Get Active programme I'll keep coming back to, because it is a great example across Wales, across the UK, which gives us insight that we are lacking around intersectional communities of disabled and non-disabled people, and the impact that physical activity can have on their lives and their well-being. And—

Thank you. I'm so sorry. I feel bad, but I want to allow time for Mabon as well. Mabon ap Gwynfor.

Thank you, Tom. A couple of observations. I think rural areas will face different challenges. I think it's inevitable, and you described some of that in your opening remarks. There are some things that we're trying to do to help support that. In terms of sport partnerships, we have a mid Wales sport partnership, amongst others, across other areas of Wales and we're really keen to ensure that they understand the needs of their communities, they engage those communities in what they perceive to be the barriers and what they perceive to be the opportunities. So it's not a supply-driven approach, it's a very demand-led approach. I think that we need to do things that utilise our natural environment to get people active. I think that's really important. And I think we need to understand, from a service provision perspective, what is available hyperlocal to those communities, what's on the doorstep, what facilities and provision may be available area-wide, what are regional, and make sure there's a relative mix that matches the needs and wants of those local communities. That's a lot of planning and system thinking. It doesn't overcome every issue. But I think unless you engage with those communities to find out what the real barriers are—. Because sometimes they are possible to overcome. Some of them are systemic and will take a long time, but we need to understand and not just move into a supply mode of, 'Well, we think the solution is x', when, actually, we haven't really understood what the barriers are.

We may have different views on this. If I may—we've talked about it today—I think a real focus on young people and ensuring that the early experiences of being active are ones that encourage people to have a lifelong enjoyment of being active, whatever that activity is.

I think from my perspective, you would have heard as part of committee over the last few months in this inquiry from experts on obesity, and I'm sure the evidence would have come through that it isn't just about personal choice. Of course, there are confounding factors there in terms of somebody's characteristics or demographic. But really, it's a societal, environmental, systemic set of failures or challenges. So, for me, a real focus on system thinking, where physical activity is planned for across different policy areas, and there's a real connectedness around taking responsibility, making it every policy area's business.

I agree fully with those two points. I think, in addition, taking some very positive thinking about how you engage those individuals and how we understand the physical activity patterns, obesity patterns for those communities that we don't necessarily see represented in data or thinking fully. So, I agree 100 per cent, but I think it's also making sure that we go a step further to look at community level, beyond just one number. Let's be better at differentiating.

There are, and we can certainly provide some additional information to the committee post this meeting. Jess, I know you've highlighted a couple of examples already. I don't know if there's any more you just want to briefly touch upon.

We have talked about New Zealand, Finland and Australia. Then there are some examples of a movement towards a preventative health strategy, and that's reflected then in budgets. I'm more than happy to send some supplementary evidence around that. And then I think when we do—Joyce talked about Norway—look at some of our Scandinavian countries, and the way that physical activity is embedded into infrastructure, and embedded into people’s lives, there are certainly some really good examples there of the way in which it just is a normalised behaviour. I’m happy to send through some more info on those.

Diolch, Mabon. That brings our session to a close today. Can I apologise that we had to curtail some of the conversation in order to get through all the questions? But we’ll send you a copy of the transcript, and if there’s anything you feel that you want to add, we would very much welcome any further input following today’s session as well. Diolch yn fawr iawn, and thank you for your advance papers as well. 

We move to item 4. There are several papers to note. There’s correspondence from the Petitions Committee regarding health-related petitions. There’s correspondence from the Welsh Government regarding various regulations, and correspondence from the Local Government and Housing Committee regarding their inquiry into the role of local authorities in supporting hospital discharges. Are Members content to note those papers? They are.

We move to item 5. I am unable to make next week’s committee meeting, so we need to elect a temporary Chair. In accordance with Standing Order 17.22, I call for nominations for a temporary Chair for the meeting on 6 February. Are there any nominations?

John Griffiths. 

Thank you, Joyce. Are there any other nominations? There are no further nominations, so I propose that John Griffiths is appointed the temporary Chair for the committee meeting on 6 February. Are Members content? They are. In that case, that's agreed. 

I move to item 6. Under Standing Order 17.42, I propose that the committee resolves to exclude the public from the remainder of today’s meeting. Are we content? We are. In that case, we draw today’s public meeting to an end.