input: What did Dr Frank Atherton said about legislation to build a healthy environment?
  Lynne Neagle AM: Good morning, everyone. Welcome to the Children, Young People and Education Committee. We've received apologies for absence from Michelle Brown and Jack Sargeant; there are no substitutions. Can I ask if Members have any declarations of interest, please? No. Okay. We'll move on, then, to item 2, which is our scrutiny of the'Healthy Weight: Healthy Wales'draft strategy, and I'm very pleased to welcome Dr Frank Atherton, the Chief Medical Officer for Wales, and Nathan Cook, who is the head of the healthy and active branch at Welsh Government. Thank you, both, for attending this morning. We're very much looking forward to hearing what you've got to say. If you're happy, we'll go straight into questions. If I can just start by asking about the fact that'Healthy Weight: Healthy Wales'is an all-age strategy, really, and how confident you are that it will deliver for children and young people.
  Dr Frank Atherton: Well, we're very confident. I mean, it has to, quite clearly. We do need to think about the present generation, the problems faced by the current generation. We have high prevalence of overweight and obesity among adults--we know that, and we can't walk away from that because that's translating into demand on health services. But we have to take a focus, a future generation's focus, almost, on the next generation. I don't write off the current generation, we can't afford to do that, but we do need to think about what can we do that would be different for the next generation so that they don't get into the sorts of problems that we're currently seeing with overweight and obesity. We know that the consequences of that for our young people are going to be enormous if we don't do something and something quite soon. We know that overweight children go on to become overweight adults, unfortunately, and that brings all the consequences of multiple disease issues--diabetes is often cited--cancer risk et cetera. So, we have to focus on children, and, in fact, during the consultation, we've been very clear that we need to engage with children and young people as well. Perhaps we'll get into that at some point, Chair, but, yes, I can give you that assurance.
  Lynne Neagle AM: Okay, thank you. What my follow-up question, really, is: can you just tell us what kind of engagement you've had with children and young people to inform the draft strategy?
  Dr Frank Atherton: Well, Nathan may be able to influence some of the detail, but in broad terms, we have discussed with young people in a number of fora. In fact, I was delighted that we had a young person, Evie Morgan, a schoolgirl from mid Wales, who came to the joint launch on the consultation. She met the Minister there and gave a very good personal account of her views on obesity and overweight. We've been visiting a number of schools during the consultation process. I'm visiting a school, either this week or next week, at Treorchy, to talk with teachers and young people there. Obviously, we're hopeful that schools and young people will contribute to the consultation as well. So, we've had quite good input, I would say, from children and young people. There is always more we can do we and we want to hear those voices.
  Nathan Cook: I was going to say, we've also had a session with youth ambassadors as well, and what we've actually produced for the consultation is not just the children and young people's version, but also a toolkit in terms of getting schools really engaged and involved in terms of the work that we want them to do to feed into this as well. So, we've already had some really good responses from a lot of youth group and schools already.
  Lynne Neagle AM: And you've got a structured programme, have you, to roll that out? Okay. Thank you. We've got some questions now on leadership, and the first questions are from Sian Gwenllian.
  Sian Gwenllian AM: Good morning. I'll be speaking in Welsh. The Minister for health said yesterday, in answering a question from me on the Chamber floor, that you gave him advice not to have a target in terms of reducing obesity among children. Could you confirm that that's what your advice was and tell us why you don't think that a target is needed?
  Dr Frank Atherton: My advice was not that we don't need a target--we may well need a target, and that's one of the issues we need to consult on--but that the target that had been adopted in England and in Scotland to halve the prevalence of obesity in children was more aspirational than deliverable, and that if we are to choose a target in Wales, then we need to balance deliverability with challenge. We need a challenging environment. So, there is something about performance management, because I would be looking to not just the health system but the health and care system and to public services boards to think about how they're delivering on this, and I think we can use targets to that. But they are one tool in the box that I would think we could use, and part of the consultation is to ask that question--'If we are to go down a route in Wales of choosing a target, what might that look like?'Sian Gwenllian AM: Okay. So, to be clear, you're not ruling out that maybe we would need a target.
  Dr Frank Atherton: It's certainly something that we could consider in terms of the final strategy.
  Sian Gwenllian AM: And is that your opinion too?
  Nathan Cook: Yes.
  Sian Gwenllian AM: Okay. Well, that is contrary to what I was told yesterday on the floor of the Chamber by the Minister, but there we go. I'm glad to hear that you're not ruling out having a target, because without a target, without something to aim for, how do we know that we're getting there?
  Dr Frank Atherton: I think your point about evaluation is really important. Whatever we produce at the end of this process--and we're looking to produce a final strategy towards the autumn--we do need to have a strong evaluation. So, some metrics in there, it would seem, would be appropriate, but what those are, what the nature of those are, do we frame them as targets or ambitions--that's the point we need to consult on.
  Sian Gwenllian AM: Okay. And the other point, of course, is the investment. If the Government is going to be successful in terms of the aim of reducing childhood obesity, then it needs to fund and support the actions. Have you made an assessment of the level of investment needed to implement this plan?
  Dr Frank Atherton: Resourcing will be important. We currently do make investments in a number of areas that relate to child health generally, and, of course, obesity and overweight in particular. So, the question of resourcing is important. Now, we can't quantify an absolute amount of resource that will be needed to deliver until we know exactly what's going to come out of the consultation and what actions we might want to deliver to a greater degree in Wales. A figure of PS8 million to PS10 million a year has been banded around as a broad kind of area of what we might need to invest, but that would need to be drawn from existing programmes. We need to look at existing programmes, how effective they are. Can we make them more effective? Can we get better value from them? And there may well be a case for new investment, and that's a question, of course, that would need to be discussed with Ministers when we're producing the final strategy.
  Nathan Cook: But I think a key consideration as well is we already know there is investment across health boards in some kind of obesity-related services. So, I think what we really need to think about across Wales is how we can drive greater scale, how we can look at current programmes in terms of making sure that they're better evaluated, and how we can make sure that we're also drawing up on the existing resources and capacity out there as well.
  Sian Gwenllian AM: And does the level of investment depend on what the target is--what the goal is?
  Dr Frank Atherton: I don't think you can necessarily just link the two. The issue of resourcing is one that's there irrespective of whether we choose to put a target in place.
  Sian Gwenllian AM: But how would we know that it's being used effectively if there isn't something to aim for?
  Dr Frank Atherton: Which brings you back to the question about evaluation. We need proper evaluation of the various programmes that we have.
  Sian Gwenllian AM: Yes, but without a target, how can you properly evaluate? If you don't know what you're trying to do, how can you properly evaluate? Anyway, you're open to suggestions about having a target, which is great. Would you agree that Government could use the revenue that's being produced through the levy on soft drinks towards some of these efforts to--?
  Dr Frank Atherton: Well, of course, there are some consequentials that are coming to the Welsh Government as part of the levy on sugary soft drinks. That funding, of course, is less than we had anticipated, and that reflects, actually, a success story because industry is reformulating, and so the amount of sugar in soft drinks is already starting to decrease, which is a good thing. But to your question: should we use the funding? Well, of course we should use funding. I'm not personally in favour of hypothecation, I think I'm more interested in the totality of resource that goes into public health programmes than into marginal resource. There are, of course, a number of initiatives that we currently fund through the general revenue. And when I think about obesity, I don't just think about the relatively small marginal amounts of money that come in through whatever source, but I think about the totality of the PS7 billion we spend in health and social care and how we can divert and channel some of that towards broad prevention initiatives in general, and towards tackling being overweight and obesity in particular.
  Sian Gwenllian AM: You're saying that it's less than expected. Could you give us any kind of figure?
  Dr Frank Atherton: I'm sorry, could you repeat the question?
  Sian Gwenllian AM: You say that there is less money that's come in through these consequentials from the levy, can you mention some sort of figure?
  Dr Frank Atherton: The figure that I have in mind is about PS56 million that's coming in in terms of revenue over a two-year period. But I'd have to confirm that with the committee. What the anticipated--. When the sugar levy was first brought in, there was some modelling at UK level about what level of revenue that would bring, but it was based on the amount of sugar that was currently then in drinks and the fact that the sugar has reduced in drinks, I mean, the total amount available to the UK is less and hence our consequentials are less. Nathan may have some precise figures.
  Nathan Cook: Yes, I was going to say, there was a mid-year report done where the levy has raised PS150 million to date since coming into force in April, and the original forecast was PS520 million a year. So, I think that shows the amount of work that's been done by industry around reformulation.
  Sian Gwenllian AM: And the consequentials of that? That is the consequential--PS150 million.
  Nathan Cook: On a UK level.
  Sian Gwenllian AM: Yes, so what's the Welsh consequential?
  Lynne Neagle AM: Fifty-six.
  Sian Gwenllian AM: Fifty-six? Gosh, that sounds a lot. Anyway, it's a good sum of money and you're talking about investing PS8 million to PS10 million. So, obviously, you know, we can be more ambitious because there is money in that pot if that money was ring-fenced for this particular scheme.
  Dr Frank Atherton: Well, the resource is going to be a real issue that we need to address, and I think as Nathan has said, there is funding of various initiatives currently in the system, and we need to look at that and make that as effective as possible. Will there be a need for some additional resource? There may well be, and that's a question that we'll have to look at in terms of the strategy when we develop it and have a discussion with Ministers about the level of resourcing.
  Lynne Neagle AM: Can I just ask on that before Sian moves on? What assessment have you made of how that money is being spent in other UK nations? Because my understanding is that the money is being used in other UK nations to directly impact on obesity. Have you given any consideration to--? As I understand it, that money now is being dispersed around a plethora of programmes, including the transformation programme, and what I found very odd, really, was vaccination, which is surely the core business of the NHS. Have you got any view on that?
  Dr Frank Atherton: I'm not sure I understand your point, Chair, in terms of the link between the consequentials from--. Are you talking about the consequentials from the sugar levy or are you talking about--?
  Lynne Neagle AM: Yes, because in other nations, it is being used to directly impact on initiatives to tackle obesity, whereas, we've kind of put it here in Wales into the general pot and it's being used to fund a plethora of different things.
  Dr Frank Atherton: Well, that cuts to what I was talking about. My preference--it's a personal view--is that hypothecation doesn't really help us too much. I mean, what we need to look at is whether the programmes, the sorts of programmes that are being funded in England, or indeed in Scotland, are working effectively, and if they are, are they being delivered here in Wales? We have looked very carefully at the plans that England and Scotland have for tackling obesity and overweight, and we've made a comparison with what we're doing in Wales, and our ambition in Wales is to go further than those nations, in many ways. But I come back to the point that just linking the hypothecation of a relatively small amount of resource is likely to be less impactful than asking a question of public services boards and of the health system, indeed, about how much money, overall, are we putting into prevention.
  Lynne Neagle AM: No, I recognise that, and I think we're talking about additional resource. Suzy.
  Suzy Davies AM: I was just wondering whether you thought that there was a useful psychological link on the part of the public between saying,'Here's a sugar levy', and'It's going to be used to help children and adults stay healthier.'Going into a pot, it actually makes it quite difficult to explain the purpose of the tax in the first place. So, I take your overall point, but in terms of the people who we're trying to help in all this, actually creating a direct link might be quite helpful.
  Dr Frank Atherton: You may be right. I'm not a behavioural psychologist. We'd have to ask--
  Suzy Davies AM: Neither am I. I'm a person who eats a lot of sugar. [Laughter. ]
  Dr Frank Atherton: Your point's taken.
  Suzy Davies AM: Thank you.
  Lynne Neagle AM: Thanks. Sian.
  Sian Gwenllian AM: The last question from me, about partnership working. You're putting an emphasis on the whole-system approach in implementing the plan, how are you going to create a system that co-ordinates action and drives change across relevant partners, avoiding a situation where it's everyone's role, but nobody's responsibility? How are you going to avoid that?
  Dr Frank Atherton: It's a very important question, and one of the four strands in the consultation is exactly related to that, around leadership and drive nationally. I'm not interested in producing a strategy that sits on a shelf. If you look around the world, there are plenty of obesity strategies. You may notice, by the way, that we've chosen not to talk about an obesity strategy but a healthy weight strategy, because I think having a positive construct is really quite important to us here in Wales. But leadership will be really important, and we will need some sort of structure to lead this, to provide oversight. I'm not a great believer in creating new structures, so we do need something that will give that drive, but the leadership comes from the top down. We need political commitment to this, and that's why I welcome the input from this committee. So, that needs to be assured. And then we need to make sure that the public sector generally is engaged in this, but it goes way beyond the public sector, of course, because we have to work with industry, and we have to work with communities, and we have to work with the public on this. So we need to think about our governance system for this and how we drive it forward. Interestingly, we had quite a large discussion two days ago between health and social care, but also involving the third sector and some members of the public, around how can we drive prevention more generally. It wasn't specifically on obesity, but of course obesity came up because it's such a pressing issue. This question of governance was discussed quite extensively, and we do have governance systems, of course, in Wales. We have public services boards, we have regional partnership boards, and how we can get those aligned behind this common agenda is really important. But I'd like to see--and I know I'm a public health professional, so I know that only maybe 10 per cent, 15 per cent, possibly 20 per cent of what makes and keeps us healthy as individuals and as communities can be driven through the health system; but I would like the system to step up and take these kinds of issues more seriously as well. So I'd be looking for local leadership through directors of public health and indeed through chief executives to work with their public services boards on this. So, we'll need some sort of national oversight, absolutely, but we need local ownership and local leadership, too.
  Lynne Neagle AM: Thank you. We've got some questions now from Janet Finch-Saunders.
  Janet Finch-Saunders AM: Thank you, Chair. Delivery of the plan will be led by a national implementation board that will be accountable to Ministers. Which Minister do you believe it should be accountable to, or, given the complexity of obesity, should the board be directly accountable to the First Minister?
  Dr Frank Atherton: Ultimately, the First Minister will be responsible for this and will want to have a strong oversight of this. It is often framed as a health issue, and the Minister, Vaughan Gething, has a strong personal commitment to this, I know. We've talked extensively with him and with sports and recreation colleagues about that, so there's a link there. It does cut across all portfolios, and so this is an issue that I have discussed with Cabinet, and that collective ownership is really important, and will be, because it can't just sit in one domain. I think what you do need to have is you do need to have a lead organisation or a lead ministry, and I would see health as--I work within health, so I'm perhaps biased, but I would see health as leading this, but it needs broad ownership across Government.
  Janet Finch-Saunders AM: I know my colleague Sian Gwenllian mentioned earlier targets and things, but I know in Wales we're not too good at collecting data. What data is currently available on childhood obesity and what metrics will be used to measure progress against the plan's objectives?
  Dr Frank Atherton: Well, of course, our main data source is the child measurement programme, which collects information on children entering school aged four or five. That's our main source of information. If we look at that data, it shows us--. Well, I'm sure you're familiar with the statistics, but it'll be just under a third of children at that age who are overweight or obese--
  Janet Finch-Saunders AM: Could I just ask--sorry to interrupt--how up to date is that?
  Dr Frank Atherton: The last survey was just last year.
  Nathan Cook: The data was published last week.
  Dr Frank Atherton: Yes, the lastest data was out last week.
  Janet Finch-Saunders AM: It is pretty up to date.
  Dr Frank Atherton: So, it's pretty up to date, and what it shows--. It's not getting radically worse--there's always statistical variation in these things--but it's not getting any better. And, for the first time last year, we did look at the question not just of children who were overweight or obese, but we actually singled out the proportion who are obese, severely obese. So we have a figure for that for the first time, which is about 12 per cent, which is quite shocking, in a way.
  Janet Finch-Saunders AM: It is shocking.
  Dr Frank Atherton: So, that's our main source of information. Does that answer your question?
  Janet Finch-Saunders AM: Yes, but how will any gaps in your data be addressed?
  Dr Frank Atherton: Well, one of the questions that are often asked is: could we measure more on a longitudinal basis? By that I mean in England, for example, children are measured at school entry and then again at year 11--at age 11 or 12. , that kind of age group. And so you do have a longitudinal view over time of what's happening to children. I think that would be helpful to us in Wales, and it's one of the questions in the consultation about whether we should expand that. Obviously, that would have significant resource implications, not just for the funding, but also for schools and for the system to deliver it. But it's something that maybe would help us in terms of better understanding and better evaluation--the point that was made earlier.
  Nathan Cook: And the other data we do have is the millennium cohort study, which has been released, for 14 and 15-year-olds. That's going to be--. We're starting to think about how we can utilise some of that data, looking at that longitudinal picture around children as well, which will be really helpful.
  Janet Finch-Saunders AM: Thank you. You've answered my next question. Thank you.
  Lynne Neagle AM: Can I just ask about the child measurement programme? The strategy commits to looking at whether we can have a second measurement taking place in Wales. Can you just tell us a bit more about your thinking on that and when you would see a second measurement taking place and how you would use that data?
  Dr Frank Atherton: I touched on that just now, but personally I do think it would be helpful to have more information. It's always the case, There's always a trade-off between the cost of getting that information and the value of the information. So, the question of how it would be used would be really important. There is still a lot that we don't know. We know an awful lot about obesity and being overweight and the causes of it, but we don't really have a very clear understanding, in Wales at least, of the point at which children start to become overweight. Although we know that overweight children tend to go on to become overweight adults, we don't know what proportion of them between school entry and later teenage years--what those changes are. So, it would help us to have some better understanding, which would help to direct some of our initiatives. I'd be generally supportive of the principle. We'll wait and see what comes out in the consultation, and it's something that we need to give thought to, but we do have to trade off the additionality of what the information would give us with the cost of doing that, of course.
  Lynne Neagle AM: Okay. Thank you. We've got some questions now on healthy environments from Dawn Bowden.
  Dawn Bowden AM: Thank you, Chair. In the draft plan, some of the measures in there suggest legislating for restricting price promotions and banning energy drinks, and that sort of thing. Do you think that, if we go down that road, there's going to be time within this Assembly to introduce such legislation? And, if not, what do you think might be the timescale for such legislation?
  Dr Frank Atherton: It may well be that there are things in Wales that we might wish to legislate on, and you've mentioned two of them, and they're good examples. We would, obviously, need to undertake quite detailed consultation on those and, in a way, we need to mirror what's happening in England and in Scotland to some degree around the consultations they're having on energy drinks. We also need to influence the issues that are not devolved to us and we seek to do that. As to your question of legislative time, I'm not really in a position to answer that. What I could say is that legislation may well be one of the outcomes of the consultation. There may well be things that we wish to choose to legislate on. The timing of that will have to be subject to other pressures, and I come back to the point that legislation, of course, is one of the tools that we've got--we need to deploy them all.
  Dawn Bowden AM: Sure, I understand that, that you could do other things. I know--. We've heard from the Government, on other calls for legislation, that the programme's very tight, certainly for this term, so I was just wondering whether we might get that in, but okay. If I turn now to the planning system--and this might not be something that you have great deal of knowledge of; I'd just welcome your view on this, because, when we discussed with stakeholders, we talked about whether the planning system, for instance, could be used to, as an example, restrict hot food takeaways around schools and so on. Would that be a measure that you would support, something like that?
  Dr Frank Atherton: I think it's definitely something we want to look at and, of course, that question is asked in the consultation, so we would like to know people's views on that. It's an interesting one. I think there is a question--a really important question--about how we can use the planning system more effectively. I've discussed with Nathan on a number of occasions, with planning colleagues in Welsh Government and in local authorities, about the art of the possible, let's say. There may be things that we could think about and we want to get those ideas through the consultation. The specific question around takeaways, particularly takeaways near schools, is often asked. I was very interested to see, up in the north-east, some time ago, that one of the local authorities up there did put a moratorium on the opening of new fast-food venues near to schools, or indeed in areas where levels of obesity and overweight were particularly high. I understand London is now--some London boroughs are now--experimenting with that as well. So, that gave me comfort, because maybe there are powers within local authorities that can be used more effectively. I think my view at the moment is that the jury's kind of out on whether those are effective and how effective they're going to be. But the fact that we have some initiatives around the UK does give us an opportunity to study that and to learn from experience perhaps and then, if it is shown to be beneficial, to think about that here in Wales, yes.
  Dawn Bowden AM: Sure, because it will only be one of a suite of measures anyway. Of itself, it wouldn't address the problem, but, added to other initiatives, I guess it would. Can I just ask you briefly, then, about community sport infrastructure and, in particular, of new schools? So, Welsh Government, as you know, has ploughed a huge amount of money into the twenty-first century schools programme. What we heard when we spoke to stakeholders recently, particularly headteachers, was that, in some of the new schools that have been built, we haven't had changing rooms and toilet facilities, for instance, built into the new buildings. So, if we're going to try and utilise these buildings for general community activity to get kids and the wider public, actually, more active, do you think that's something that we ought to be building in? Again, not your particular direct area of responsibility, but something that you might have an input into, is that, when we're developing schools, we should be making sure that they have those kinds of facilities so that they become accessible to the wider public. Is that something that you would be prepared to make a recommendation around?
  Dr Frank Atherton: Well, it's certainly a fascinating area and one that I think has a lot of potential. It goes--. You're right to raise it in the context of schools, and I can understand why this committee would, but I think it goes beyond that, actually, into all developments in the public sector and how they're developed and whether we're building health into our environment, which perhaps is your starting point. One of the things that I was really pleased to see in terms of the Public Health (Wales) Act 2017 that was passed a couple of years ago was the use of health impact assessment as a tool, and we're still working on how that will inform policy and how that will be applied in issues such as policy decisions through Government, but also in more downstream issues about how we create the public infrastructure that the public can and should be using. And so I would like to see the use of health impact assessments to a much greater degree to inform those kinds of decisions. If you apply that kind of lens and you take the point, which is inherent in your question, I think, that schools are not just for kids, they're for communities, then you would--it would lead you to a conclusion that you would perhaps design and build them in a different way. So, on a personal basis, I would certainly support your view that we should be looking to use the sports environment in schools in the same way as we use leisure centres. There are all kinds of barriers in there, and I understand all of that, and it's not really my field, exactly as you say, but, as a matter of principle, I think it's a good one to pursue.
  Dawn Bowden AM: Okay. Thank you. And widening it out to other public services buildings as well.
  Dr Frank Atherton: Indeed.
  Dawn Bowden AM: Yes. Okay. Thank you.
  Lynne Neagle AM: Okay, thank you. We're going to move on now to talk about how we create healthy settings. I've got some questions from Suzy Davies.
  Suzy Davies AM: Thank you very much. Yes, perhaps if we could just stay in this area of education just for a moment, I think we all agree that healthy habits acquired early on probably tend to last quite well, so I wonder if you can tell us a little bit about the healthy and sustainable preschool scheme and whether you think some timescales should be made public about what you expect the achievements from that scheme to be. But, in particular, I was struck with what you said about local leadership, and I just want you to bear that in mind in answering the next question, which is about the foundation phase. You're probably aware that this committee has heard from various school leaders that they're struggling in some cases to meet the ratio of staffing for the foundation phase, which potentially compromises the purpose of it in terms of physical activity. I'm just wondering how the strategy development board is considering that at the moment. Is it something that's come on the radar for the board? Is it something you're thinking about? And, if so, who do you think should be responsible for pinning that down a little bit? Because this is education, not health, and--.
  Dr Frank Atherton: Well, look, I've got to confess to you, I'm not an educationist, and so the question on staffing numbers in schools is not one that I have been asked to give a deal of consideration to, and it hasn't really been discussed, I don't believe, in the context of development of the strategy. If there is a specific point around that that the committee would like to make in terms of a response into the consultation, which I presume you'll be making, then we'd be happy to consider that. As to healthy preschools, I don't know, Nathan may have some view on that. I've not been closely involved with the work. We have standards and we perhaps need to think about how we tighten those standards and how we--enforce isn't the right word, but how we implement and make sure that those standards are properly implemented, because you're absolutely right to say that habits are developed early in life. That's in the preschool; it's also in the home of course, and then later in the school. So, we do need to look at all of those as settings and are there more things we can do within those settings to drive healthier behaviours--that's exactly why we need the consultation.
  Nathan Cook: But I would say, through that scheme as well, we've really got a really good bank of preschools that are actually doing some really great work in this area as well. So, I think the more we can understand the successes that some of those environments are having--you know, how we can roll those out and work across other settings to create that wider impact as well is going to be really important.
  Suzy Davies AM: Okay. Thank you. What I'm thinking about is expectations at that level will be expectations at a slightly older level, which will be contained within the foundation phase. And while you're quite right--obviously, parents have a role in this, or families--there will be, particularly with the introduction of the new curriculum, certain expectations on schools to provide not just healthy environments but to actively work towards well-being and healthy weight in children and things. And that's why I asked you about local leadership, because, if it fails for reasons that have nothing to do with the plan at foundation phase, it's going to fail further up the school years as well. I think it might be something that the board might want to consider here, because at some point there'll be an accountability question and we will want to know how'Healthy Weight: Healthy Wales'fits in with the new plans for the new curriculum, and whether it's merely persuasive and influential or whether it has the weight to place some obligations on school leaders about what they do in their schools. So, this connection, I think, is quite an important one, and, if the strategy development board could consider that, I think it would be very helpful, because this doesn't exist in a vacuum.
  Dr Frank Atherton: Well, I'd certainly be delighted to take that back and we can look at it in terms of how we move from the consultation into the final strategy. It's certainly a point we can try and look at.
  Suzy Davies AM: Because we will want to know who to ask:'you're the accountable person--why has something worked, or not worked?'We will need to know that at some point.
  Dr Frank Atherton: Just building on Nathan's point, some of the schools--I know it's schools rather than the preschools, and I take your point, but some of the schools we've been working with have absolutely brilliant models of good practice and good local leadership. I remember the Minister actually at the launch, and one of the schools was represented there, and they presented--the school came and some of the children came and presented--to the whole audience about the activities that they were undertaking in their school around physical activity and on healthy eating, and it was such a model of good behaviour the question was,'Well, why not everywhere?', so that probably speaks to your question.
  Suzy Davies AM: Okay, well, thank you for that commitment anyway.
  Lynne Neagle AM: And have you had any discussions, then, with education officials around things like teacher training and CPD, because you'll be aware the Health and Social Care Committee has made a number of recommendations in this area? It's crucial that we skill up the staff to develop these things in an appropriate way, isn't it?
  Dr Frank Atherton: Well, we certainly discuss with education colleagues in Welsh Government. There's more we need to do in terms of that, because you're absolutely right: there's something about building the whole of the workforce--education is really important, but elsewhere as well; it's about how do we really make every contact count, you know, that construct. So, everybody who's working in the health and social care system should have a role in this; everybody who works in education, whether it's the old--. Do we still have dinner ladies? Or teachers, you know, they have a role to play in supporting children to be as healthy as they possibly can. And, actually, I see them, Chair, as a really essential part of the public health workforce.
  Lynne Neagle AM: Okay, thank you. Suzy, are you going to do your curriculum one?
  Suzy Davies AM: Well, I've bound it in together, but that final point you make about teachers being part of the answer to this, they're already under a range of pressures: is it fair to make them accountable for whether this works or not? Or should that local leadership lie somewhere else? I don't expect you to pin down a person today.
  Dr Frank Atherton: I wouldn't like to blame a teacher or performance manage them on the proportion of their children in their class who are overweight. That would clearly be nonsense, wouldn't it? But they are part of the solution, and so the accountability lies further up the chain, doesn't it? The question I think we would have, and public services boards might well ask, and the local education authorities may well ask, is: how effective is any particular school at driving forwards these healthy behaviours?
  Suzy Davies AM: Okay, thank you. I'll leave some questions for Hefin.
  Lynne Neagle AM: Hefin.
  Hefin David AM: Is that all right, Chair?
  Lynne Neagle AM: You've got the floor, Hefin.
  Hefin David AM: Thank you, Chair. You make a commitment to embedding physical activity at an early stage in primary school education. What would that look like?
  Dr Frank Atherton: Just in terms of the physical activity, I have to say it's a really important dimension and we need to move further on. We know not enough of our children are physically active and they're not meeting the various guidelines, so it's really important. It doesn't actually have as much of an impact on weight as the dietary issue. I'd just say that. It's really important for all sorts of reasons. It does have an impact on healthy weight, but it has a huge impact in terms of socialisation, in terms of mental health issues, et cetera, you know. So--I'm sorry, I've lost track of your question.
  Nathan Cook: I'd just say that one thing we have got in train is, obviously, Sport Wales, Public Health Wales and Natural Resources Wales--we have them working together as a collaborative at the moment to look at how their joint delivery on physical activity can be taken forward more efficiently. So, one of the things they are looking at is obviously the schools programmes they do through eco-schools, the Welsh network of healthy schools and the sports programme to really think about that physical activity and how we can have better join up in terms of the programmes that we're already delivering as well.
  Hefin David AM: With that in mind, I'm going to confess to you, chief medical officer, I did anything in school I could to avoid physical education lessons. I hated it. I didn't feel engaged with it. Yet, two weeks ago, I played for the Assembly rugby team--I wanted to get that in. The school sports survey, that would suggest that we're still not hitting those targets with children. How can we get children more engaged with physical education in ways that--? I felt completely alienated in school.
  Dr Frank Atherton: Well, you're right, and many people go through that same journey and come to physical activity later in life, and that's great if they do that. The sad reality is that many people don't, and we also know that there are issues around the dropping off, particularly for girls, of physical activity towards the teenage years. So, there are specific moments that we need to understand. We do have a lot of information about these kinds of things. Public Health Wales is very good at collating the information. We do need to turn that into programmes. I mean, at the heart of it, it's about making sports and physical activity enjoyable and attractive to people. Sometimes that's easier, I sense, for boys than for girls, but we need to tailor things to different audiences.
  Hefin David AM: Yes, that's the trick, isn't it? It's about finding out what children enjoy doing. That could be quite a wide and varied range of things. Is that the key?
  Dawn Bowden AM: It's not all about organised team sports.
  Hefin David AM: Yes. As Dawn said, it's not just about organised team sports. There are some very individual activities you could do.
  Dr Frank Atherton: Absolutely, yes. And that's where I think--. I'm delighted that Sport Wales has moved beyond. It's not just about elite sports; it's about getting everybody engaged and active in sports, and that partnership with Public Health Wales that Nathan talked about is really important, because we need a population approach to driving physical activity.
  Hefin David AM: So, do you think, with that in mind, we need statutory guidance for schools on physical education?
  Dr Frank Atherton: Again, I'd look to the consultation as to whether there was an appetite for any kind of guidance. It may well be that that is something that could be considered.
  Hefin David AM: Okay. And finally, with regard to free school meals to all pupils in primary and secondary schools, do you think that extending that to all pupils would be beneficial in providing a more varied diet for pupils?
  Dr Frank Atherton: I don't have a personal view on that. I think it's the quality of the food that kids are getting, whether that comes from home or through school, and whether it's free or whether it's paid for. I think it's the quality of the food that we need to focus on. The question of children being hungry at school is a really important one and needs to be addressed at a national level. I think that's a--
  Hefin David AM: So, you think that's more about the provision of food for those who might not have access to it than providing a varied diet.
  Dr Frank Atherton: I think it's important that children have access to food, absolutely, if that's your question, but we also need to look at the quality of the food and what's in that food offer.
  Hefin David AM: But you don't necessarily think universal provision would--.
  Dr Frank Atherton: I don't have a clear view on that. I know there's a larger debate about that.
  Hefin David AM: Okay, thank you.
  Lynne Neagle AM: I've got some supplementaries from Janet and then Suzy.
  Janet Finch-Saunders AM: Yes. I've been around some amazing schools in my own constituency, where they've got proper canteen facilities for pupils and really, really good produce in the meals. However, there's probably only a third having school meals; the rest are packed lunches. And, to be honest, I've been very surprised and shocked at what I've seen of the quality of the food in the packed lunches. Nobody can really police, and I wouldn't want to see parents being policed over what goes in a packed lunch, so if there is data out there to suggest that there's a larger percentage of parents providing packed lunched that are really not good at all, then there is some merit to be said for what Hefin is--. Me, personally, I'd love to see the introduction of universal school meals. I think it's been a very retrograde step, going backwards. Would you be willing to carry out any research?
  Dr Frank Atherton: So, I mean, your point about food that's brought in in the packed lunches is a really important one, and I've talked to some headteachers as well about this. We could go down a route of guidance and prohibition, but that gets you into the role of nanny in chief and I don't really see that as my role or Government's role, and I don't think it's effective either. Do you remember--? You must have seen on tv--I think it was in Scotland; I don't know if it's happened in Wales--parents pushing the fish and chip packets through the school railings. We don't need to get into that. What I have seen, though, is some really good innovative practice in schools where, for example, they reward children for bringing the healthy options. Schools can give guidance to parents about what would be a healthy lunch and what sort of things might be expected to be seen in the lunch box. And you can reward children, and children do respond to rewards. So, I've seen some of those approaches that have transformed, actually, the offer of what comes in school boxes. But I think just banning chocolate bars and crisps in the packed lunch is unlikely to be successful.
  Janet Finch-Saunders AM: We can't do that. So, my point to the question was: isn't there some merit, perhaps, about all children being equal and eating similar good-quality food in schools?
  Dr Frank Atherton: Yes. That gets you back to the question about universal school meals.
  Janet Finch-Saunders AM: Perhaps some of that PS56 million sugar tax, even. Who knows?
  Lynne Neagle AM: Suzy.
  Suzy Davies AM: Yes. Mine is just a short question. The draft plan commits, doesn't it, to updating the healthy eating in schools regulations--the 2013 regulations? I appreciate this is a consultation, but what is it that needs changing in those regulations at the moment, just to give us a bit of steer?
  Nathan Cook: It's mainly on sugar content, so, obviously, they don't adhere to current Scientific Advisory Committee on Nutrition guidelines around sugar levels. So, what we'd want to consider is, you know, what we need to be careful of is unintended consequences of changing that, as well, if you see a shift to more kids bringing in school packed lunches as well. So, I think we want to consider the best way of doing that and consider through the consultation how we can go about it.
  Suzy Davies AM: All right. So, it's very pertinent to Janet's question, in that way. Okay, so it's mainly about sugar, but it could be about other things as well. Okay. Thanks.
  Lynne Neagle AM: Okay. The next questions are from Janet anyway; firstly, on the clinical obesity pathway.
  Janet Finch-Saunders AM: The'Healthy Weight: Healthy Wales'plan commits to a review of the clinical obesity pathway. What are the time frames for this review, and what do you think are the basic essentials of a clinical obesity pathway for children and young people?
  Dr Frank Atherton: We do have a pathway for managing overweight, and that's been in place since about 2010, I believe, and we do need to bring that up to date in terms of current knowledge and experiences. We've challenged Public Health Wales; we've asked Public Health Wales to undertake a review of that pathway, and they are going through that process now. I'm not sure of exactly the time frame that we have given them for that.
  Nathan Cook: We were asking them to review the pathway before we launch the final strategy in October because, obviously, what we want is for that to inform what that final strategy looks like. So, we'll be looking probably early autumn for them to report back on that.
  Dr Frank Atherton: The second point of your question about what are the essential elements, I mean, they are already there; we need to tweak them and we need to make sure that they're properly delivered. But it's a tiered approach, so, having access to information through schools and through communities and into families is part of the first step of that. And then, if children are overweight, it's a question about how they're identified. There are questions about the ability of the public to recognise large children, so there may be an issue there. But when children are running into issues around weight, what kind of interventions can be put in, either through primary care or through communities through health visitors, et cetera? And then of course we do have--and we've started to shine a light on this, haven't we--the very overweight children. I don't think we have enough in the way of targeted support to be able to support those. There are programmes available, but they're perhaps not universally provided. So, I think there's something about looking at our whole pathway, mapping out what the current evidence now shows us is needed, and then thinking about what is our provision in Wales and what do we need to do to bring that up to the level of the places that are the best.
  Janet Finch-Saunders AM: Thank you. The draft plan recognises the importance of the first 1,000 days, but it doesn't appear to include any new proposals to help parents to enable lifestyle changes. It lists existing initiatives, such as the Healthy Child Wales programme and breastfeeding action plan. Are you satisfied that the draft plan does enough to address the influence that family and parents have on children's healthy weight behaviours, particularly in the first 1,000 days?
  Dr Frank Atherton: Well, the first 1,000 days are really critically in shaping lives, as I'm sure you'd agree. We are absolutely open to any other suggestions that the public or this committee have as to what more we can and should do. There are a number of things, the sorts of programmes you've mentioned, that I think could be more effective. We're currently looking at breastfeeding because it starts before birth, actually. We know that children who are breastfed are less likely to suffer from obesity in childhood and, indeed, to go on to be obese adults. So, we do need to go further on that. We do have some programmes--Healthy Working Wales, et cetera--that need to be improved. If there are other interventions in other areas that we need to take, then we'd be delighted to hear what they are, but those are the ones that have jumped out so far.
  Nathan Cook: Can I just say--? One of the proposals we're looking for is, obviously, we know that during pregnancy it's a really critical time when we can actually look to work with mothers. We know from looking at some of the behaviour change that it's actually a really critical point when new mothers really start thinking about their lives, wanting the best for their child and their families. So, what we are thinking about is how we could develop some kind of approaches to that going forward. But we know our Healthy Start scheme is also a good lever for us, just in terms of how we can look to improve that kind of dietary offer at the earliest stage as well.
  Janet Finch-Saunders AM: Thank you. Finally, we know that for some families day-to-day challenges can make it difficult for them to make healthy choices, particularly for those on lower incomes and/or maybe using food banks. Could the Welsh Government take bolder action to better support low-income families to eat healthily?
  Dr Frank Atherton: Well, you've touched on a really important point about inequalities because overweight and obesity is not evenly distributed across our population. It absolutely is more prevalent in more socioeconomically deprived communities, and that's something that should really concern us all. So, it gets you to questions of availability of fresh food and produce; it gets you to questions of formulation of products and whether value brands are less healthy than more premium brands. So, it cuts across all of those issues that we talked about in terms of settings and in terms of environment earlier. There is something about the affordability of good-quality healthy food that we need to think about. We do need to think in broad terms--broader terms than just obesity, but we do need to think in broad terms--about how we create a society where families have the wherewithal to lead healthy lives, and that gets you to really important questions about the minimum wage and income poverty. There's no doubt in my mind--I'm a public health professional--and there's no doubt in my mind that economic success and health success go hand in hand. So, you speak to a very deep question there. In terms of what we can do through this particular consultation, there are some things in there about providing better access, but without tackling some of those deeper determinants of health, their impact will necessarily be limited.
  Janet Finch-Saunders AM: Thank you.
  Lynne Neagle AM: Just finally from me, then, you referred earlier to the importance of making every contact count, but some stakeholders have told the committee that they struggle to do that because of difficulties in availability of people to refer to. Is that a situation that you recognise and what, really, can we do to improve that situation?
  Dr Frank Atherton: Well, it depends what you mean as to where to refer to. So, the health system obviously needs to respond to this issue. What we're seeing across the NHS is a gradual transformation in primary care so that primary care is no longer about going to see your GP, it's about going to see a practice where you have a range of health professionals. Would I like to see more dietetic support, for example, in that setting? Absolutely I would. I think we need to think in terms of that pathway that we were talking about earlier, about access to that kind of advice and support, which can head off people getting into problems and kids getting into problems with weight issues. So, that question of redesign of the pathway really speaks to, I think, your point about,'Well, where do people go when they have problems with their weight?'That's true for adults and it's true for children as well.
  Lynne Neagle AM: Okay, thank you. Are there any other questions from Members? No. Okay. Well, can I thank you both very much for your attendance? It's been a really productive session. We appreciate your time. You will be sent a transcript to check for accuracy in due course, but thank you again.
  Dr Frank Atherton: We'll do that. Thank you, Chair, and thank you to the committee, because getting some input into the consultation from children's perspectives, this would be one of the routes we would absolutely welcome. Thank you.
  Lynne Neagle AM: Okay, thank you very much. Item 3, then, is papers to note. Paper to note 1 is a letter from the Welsh Health Specialised Services Committee on CAMHS tier 4 provision. Paper to note 2 is a letter from the Minister for Health and Social Services also on CAMHS in-patient provision. Paper to note 3 is a letter from the Children Commissioner for Wales on tier 4 CAMHS provision. Paper to note 4 is a letter from Qualifications Wales to the Minister for Education on qualifications for the new curriculum. Paper to note 5 is a letter from me to the Minister for Education on the development of the new curriculum. Paper to note 6 is a letter from me to the Minister for Education seeking clarification on the draft additional learning needs code. Paper to note 7 is a letter from me to the Minister for Education seeking clarification on the response to our Brexit report. Paper to note 8 is a letter from the Equality and Human Rights Commission on a cumulative impact assessment briefing for committee, which has been offered. Paper to note 9 is a letter from the Chair of the Petitions Committee on a national taskforce for children's mental health. Paper to note 10 is a letter to the Secretary of State for Exiting the European Union from the children's commissioners for England, Scotland, Wales and Northern Ireland on the implications of Brexit for children. There are a few that I'd like to return to in private, but are Members happy to note those? Thank you. Okay. Item 4, then, is a motion under Standing Order 17. 42 to resolve to exclude the public from the remainder of the meeting. Are Members content?
  Suzy Davies AM: Yes. There's somebody up there.
  Lynne Neagle AM: Thank you.
output: According to Dr Frank Atherton's answer to legislations'timing, it was very clear that the implementation of legislation to build a healthy environment was very approved by Dr Frank Atherton and even by a large group in the consultation. Dr Frank Atherton reviewed that they needed a mirror to see what had been happening in this country and legislation was a good way and took some examples of food takeaways which showed that they needed to consider effectiveness things.