Dolly Theis is completing her PhD at Cambridge University’s MRC Epidemiology Unit. She contested Vauxhall in the 2017 general election.
This article is the last of the mini-series of three I have written about obesity policy for Conservative Home this week.
First, I set the scene and explained why obesity policy affects us all.
Then I rummaged around in the Conservative Party’s own history, beginning with Sir Robert Peel, to find out what previous Conservative Party “greats” have done to solve nutrition problems and see what we might learn.
Finally, today I will set out why I think we have failed to tackle our broken food culture and system, and what I think Government should do going forward, which I don’t think will be what you expect.
Believe it or not, there have been almost 700 obesity policies proposed by the UK Government since the early 1990s. Despite this, obesity rates have continued to increase.
Given that government has proposed so many policies, why haven’t they worked? And what exactly should happen next? I am a final year PhD student examining obesity policy in England, and believe that I may have identified some of the potential answers.
To anyone who thinks a PhD makes me some kind of expert, let me say now that the main thing one learns completing a PhD is…just how much one doesn’t know.
However, I think it is critical, especially at a time when we are bombarded by statistics and differing “expert advice”, to communicate research live, as transparently and as much as possible. So here are my findings and thoughts on these whopper questions so far.
A Conservative Government under John Major first recognised obesity as a problem government should seek to reduce in 1991. The following year, that government published its Health of the Nation public health strategy, which included the first ever government obesity reduction targets – to reduce the proportion of obese men to six per cent and obese women to eight per cent by 2005. Clearly, these were not met.
Since then, 13more government obesity strategies have been published, and yet obesity rates continue to rise. Given this failure to successfully tackle the issue – despite almost 700 policies in 14 government strategies – what should happen next? And can we really hold out any hope?
As an optimist, I will immediately answer the second question with a firm yes – but what I think should happen next requires a little bit more explanation.
The obesity policies proposed by government over the past three decades have been far more repetitive than one might expect. These include: nutritional guidelines for the catering sector, planning powers for local authorities relating to outdoor spaces, the provision of nutritional information, reformulation of food and drink and the development of healthier marketing practices.
You would be as likely to find these in a strategy today as you would have been in 1992. Indeed, you do. Just compare policies in Health of the Nation to the Government’s more recent Childhood Obesity: A plan for action strategies (2016, 2018 and 2019) and Tackling obesity: empowering adults and children to live healthier lives (2020).
So why do we keep proposing the same thing? From what I can see there are three possible explanations.
- Government proposes policies but doesn’t necessarily implement them. It then ends up reproposing the same ones.
- When government proposes policies that require action from other actors/sectors (industry, schools, workplaces etc), it doesn’t appear to create conditions conducive to high compliance – so they don’t do what has been suggested; and
- Government rarely seems to evaluate often, consistently or well.
These are pretty major policy making problems and each one alone could explain why government has failed to tackle issues such as obesity.
What government should do is start with doing the above better.
It currently proposes obesity policies in a way that does not readily lead to implementation, which is likely to be why it does not then implement its own policies. Could you imagine the same happening in business? No, you couldn’t imagine that because it just wouldn’t happen.
Yet obesity policies are often proposed without a clear responsible agent, timeframe, theory of how they will achieve the intended change, cited evidence on which the policy is based, an independent evaluation plan (self-evaluation cannot always be relied upon) and more shockingly, the majority of policies are proposed with no cost or budget.
In some cases, policies are reproposed in a laughably short amount of time. For example, Chapter 2 of Childhood obesity: A plan for action was published in 2018 under Theresa May. It contained a number of policies, including a 9pm watershed on unhealthy food and drink advertising, and committed to legislating mandatory calorie labelling in the out of home sector.
Consultations were conducted. Individuals and organisations submitted their evidence, reflections and advice. Then poof! Two years later, instead of having implemented the policies, the Government, now under Boris Johnson, publishes another obesity strategy containing those exact same policies and another consultation process.
They say madness is doing the same thing over and over again and expecting different results. Well, hello…
So here we have government proposing the same things again and again. We also have it proposing many policies for other sectors to implement.
Three cheers from anyone not keen on government regulation and legislation. But, hold on! Don’t get too carried away – because government proposes policies in such a way that does not readily lead to high compliance. The result is that sectors don’t do enough or don’t do anything at all, so government is pushed more and more into the regulation and legislation corner. It could potentially address this by meeting the compliance conditions set out by Australian academic, Professor John Braithwaite – who is basically the king of compliance and regulation.
I know regulation and compliance are sexy subjects – so strap in everyone.
Braithwaite argues that to increase chances of high compliance, governments should start with capacity-building – i.e. learn about the issue of interest, what needs to be done, who needs to act, what they need to make that happen etc.
Then, it should escalate to suggesting those actions to the responsible actor(s)/sector(s). Governments can name and shame, depending on progress, and state how they will move to more deterrence measures (e.g. taxation, laws, etc) if not enough progress is made.
As a last resort, an actor(s)/sector(s) could be fully incapacitated where action/inaction is deemed harmful.
So as government escalates up from capacity-building to stronger deterrence measures, the order of action ishould always be:
- Building strong relationships with the responsible actor(s)/sector(s).
- Ensuring consistent and independent progress evaluation.
- Building legitimacy (i.e. make sure every actor involved enjoys a full understanding of the purpose and consequences of complying).
- Support capacity building to ensure the responsible actor(s)/sector(s) can actually do what is being asked; and
- Ensure the whole process is transparent so third parties/sectors can hold those responsible to account.
Ok, everyone take a breath.
The problem of evaluation is addressed in achieving compliance, but I will make the point again here just in case. Policies should always be evaluated, ideally by an independent body.
Rob Baggott analysed various public health policies in England in 2012, and found that government evaluation was either tightly controlled to minimise criticism, conducted in way that made lessons for future policy ambiguous, or not conducted at all.
Government must stop this. How is it supposed to know whether something worked if it is not evaluated properly? We also do not always have high-quality evidence about certain interventions and, in some cases, can only build this by introducing the intervention first.
For example, to really know what the impact will be of a taxation policy such as the sugar tax, government must first introduce it, and then monitor the various impacts closely over time in order to build high-quality evidence.
Government must therefore be bold in introducing interventions that have the potential to make it easier for us to live a healthier life, and then build the evidence through high quality evaluations.
In Amsterdam, the city authority refers to this as “learning by doing”, whereby they tweak and adapt interventions, rather than dichotomously declaring “it worked” or “it failed.”
You may have expected this article to contain a list of obesity policies for government to introduce such as nutrition education in schools or cooking lessons for the general public – but, as I say, there are literally hundreds of recommendations already proposed.
The policies to tackle obesity are all there in the 14 government strategies already published, from reducing the bombardment of unhealthy products while also increasing the provision, convenience and appeal of healthy products. Henry Dimbleby’s 2020 National Food Strategy is also one of the most comprehensive, “oven ready” policy packages ready for implementation.
We must stop searching for more magical solutions – and instead begin implementing and evaluating policies already proposed. Only then will we move closer to creating a world in which it is easy for us all, regardless of circumstance, budget or where we live, to enjoy a healthy life.