On The Nation:

Patrick Gower interviews Health Minister Jonathan Coleman

Minister doesn’t know what’s happened to the estimated 160,000 patients who failed to get a specialist appointment after being referred by their GP but is now trying to find out

Major work underway to count and understand what’s happened to those patients should give a true picture “later next year”

Coleman says Education Review Office to go through all schools in NZ to find out which are “struggling” with nutrition, food and physical activity

“I want to know where the problems are, where are the schools with the obese kids, where are the kids at the schools that don’t have healthy-eating policies”

However says that won’t lead to a ban on junk food or “blanket regulation” but working with boards of trustees and health promotion

When asked about WHO report that taxes do influence consumption, Coleman replies: “So, for instance, there might be a decrease in consumption of soft drinks, but are people drinking more flavoured milk? Are they drinking beer as a substitution?”

Coleman says could have set an “unrealistic, aspirational” target to bring down childhood obesity but Government can’t control all the “levers”

Says New Zealanders are eating too much sugary food but there’s not “conclusive evidence” for fizzy drink tax

Says National’s health funding has kept up with population growth and “most inflationary pressures” after Infometrics report found shortfall in real terms.

Patrick Gower: When Health Minister Jonathan Coleman launched his plans to combat obesity this week, what was off the fat-fighting menu made more headlines than what was on it. That's right...no soft drink tax, no junk food ban in schools, and no actual target for a drop in obesity rates. The 22 initiatives include a review of food advertising to kids and targets for referring obese children to specialists. But how effective will these measures be? Political editor Patrick Gower sat down with Dr Coleman and began by asking him what actually happens once a child is identified as obese at a pre-school check.
Jonathan Coleman: They will then get referred to appropriate professional advice, so that may be their GP; it may be a paediatrician, and there will then be interventions based around the whole family, because, of course, a child doesn’t live in isolation. A lot of these issues are around family culture. So there will be intensive interventions. It may be information, but it may also be sending people off to programmes like Healthy Families, which is going to cover a million New Zealanders, where they can learn about practical cooking, they can get exposure to the type of exercise interventions they need. So, look, the key thing is it’s very practical help. It’s not just about guidelines and referrals; it’s about getting people access to the interventions they need. And don’t forget this is one of our six main health targets. No other country has a national-level health target around obesity. And it’s backed up by a very comprehensive cross-sectoral package of interventions.
Sure. So it’s up to the doctor, then, isn’t it? Because that’s where they will go in the first instance – to the GP.
Well, so, the before-school check is generally done by a nurse in the community. When these children are identified as being obese on the height and weight growth charts, the nurse will then make a call as to what the appropriate referral will be. It may be the GP; it may be more specialist help. It could arguably be a dietician. There’s quite a lot of flexibility, but we’re going to make sure these children get the interventions they need.
That target of obesity, it’s not actually getting obesity down, is it? The target is around referrals. Why haven’t you made the target around obesity itself?
Yeah, that’s a good question. I mean, in the end, with a target, you’ve got to look at what levers you’ve got to control that target – what existing infrastructure you’ve got. Now, we could have set an unrealistic, aspirational target, but the government doesn’t have control over all those levers. And in the end, it comes back to this thing – the government is not the answer to everything. But what we knew we could do—
But why? I just want to pick you up on that, because why is reducing obesity – why is that aspirational? Surely that should be the target.
So, if we just said, ‘Look, we’re going to reduce obesity by X%, well, that sounds great, but actually we don’t control all the steps along the pathway to make that happen, whereas with this target we’re signalling really serious intent. We know that this will make a difference to that group of children and that we know that by putting the emphasis on what’s required to achieve that target, you’re actually going to be able to make progress towards achieving it.
Yeah, but at the same time, you’re almost saying that reducing obesity or actually putting a real measure there – something genuine; what we need to do is reduce obesity – you’re sort of saying that’s unrealistic.
No, I’m not saying it’s unrealistic, but, look, all these things are steps along the path, right? We’re the first country to ever have a national-level target with a comprehensive programme underpinning it.
Do you think there is too much sugar in food?
I think people are eating too much sugary food. Some foods have too much sugar in them, and what we’ve got to do is make sure that industry continues to reduce sugar. So it’s a case of everything in moderation. Look, if you’re going to be drinking, you know, five cans of Coke a day, seven days a week, it’s not going to be good. If you’re going to have one on Saturday after rugby, that sounds fine.
You’ve justified not contemplating any form of junk-food tax by saying there isn’t enough evidence.
Well, you’re saying a junk-food tax. You mean a sugar tax.
Sugar tax.
Yeah, okay. Soft-drink tax.
Looking at a soft-drink tax –why not?
Because, actually, there’s not the conclusive evidence, right? There might be a correlation in those Mexican studies, so they put a 9% tax on soft drinks.
And consumption dropped. That’s evidence, isn’t it?
Sales decreased, but it’s not clear if that’s a correlation or a causative effect, so there were other things going on – a tanking Mexican economy, $30 billion drinking-water programme. It’s also not clear if there’s substitution to other beverages. So we’re saying, look, you know, there’s some evidence that’s being assessed – it’s going to be reported on in 2017 at Waikato University as well as the University of North Carolina – but there isn’t any direct evidence of causation that anyone can point to.
Well, the World Health Organization, which put out that major report recently, led by our own Sir Peter Gluckman, you know, that has said, and I will quote it for you, ‘The rationale and effectiveness of taxation measures to influence consumption are well supported by available evidence.’
Well, they might be talking about a decrease in sales. But what we want to know about is – is there a link to obesity directly? So, for instance, there might be a decrease in consumption of soft drinks, but are people drinking more flavoured milk? Are they drinking beer as a substitution? What is says in that report is that, actually, there isn’t clear evidence. On balance, they recommend it, but, look, that’s the WHO, you know? You would expect that they would take a very purist view. And I met with the commissioners personally. I talked to Sir Peter Gluckman.
What about this for evidence? If a tax doesn’t work or there’s no evidence for it, what about with cigarettes? Because your own government’s putting up the price of cigarettes and saying that that is working to stop smoking.
Well, that’s a different issue. So, yes, if you put a tax on something, it will decrease consumption, but what I’m interested in is – will that decrease obesity? So say, for instance, we tax something. You might drink less Coke, but are you drinking beer or flavoured milk instead?
22 initiatives.
Yeah.
What’s one thing that the food industry has given up here in all of this? Because I can’t see anything.
Okay, well, the food industry initiatives – first is the health star rating, right, so clearer information on labelling.
Voluntary?
Yeah, but I think they’ll find increasingly consumers are going to demand that. The second thing is there’s going to be independent auditing of their compliance with the ASA codes on advertising to children and food, right? Only nine complaints under those codes over the last five years. The third thing is the ASA is reviewing those codes as a priority. Fourth thing is I called together the food industry, addressed them by teleconference, got them to work with health officials and said, ‘Look, this is a major issue. We need you guys to be part of the solution.’ They’ve accepted that. They’re doing things. Coca-Cola Amatil – they are not supplying their products directly into schools any more. Neither is Frucor.
Yeah, but…
There’s been big initiatives on—
…soft drink is still getting into schools, and that just to me seems like an absolute no-brainer. Why don’t you ban soft drinks in schools?
Well, because what we’re looking at is across the thousands of schools in New Zealand, I want to know where the problems are, so I go to many, many schools. Some of them, there are obese children. Some of them, there are barely any. Some of them, there are virtually none. So I think it’s far more effective to work with those schools where the problem is. If you look at the reaction to the package—
But you don’t know those schools.
We’ve got to get that information.
And how are you going to get that?
Yeah, so in the Cabinet paper, it describes how ERO is going to go and give us a report on the state of nutrition, food and physical activity in our schools.
Will that go school by school? Because that’s what’s needed.
Terms of reference have to be drawn up, but that’s the information I want, because—
You want to go school by school, know what the good schools are, what the bad schools are?
Look, it’s not going to be naming and shaming, but I want to know, and broadly there’s a correlation with demographics, including socio-economic levels. I want to know where the problems are, where are the schools with the obese kids, where are the kids at the schools that don’t have healthy-eating policies? The other thing is we’ve got these health promotion schools—
So you would get a list effectively, by the sounds of things?
Look, we haven’t defined it down to that level, but ultimately I’m very interested in knowing which those schools are which are struggling. And, look, I think a lot of it’s around working in schools—
And this is the crucial bit here – once you get that, what are you going to do to those schools?
So the first thing is you’ve got boards of trustees there, talking to them around what a healthy-food programme might look like, looking at what sort of foods they’re serving in schools, trying to get them into the health-promoting schools. So we’re expanding that. That’s one of the initiatives here, whereby the whole school environment is focused around health. Look, the key point about this—
Would you be prepared in the end—?
Can I just say there’s a lot that can be done without blanket regulation.
If you got that list and there is a repeat offender school that has a problem and the board can’t sort it out, would you be prepared in the end to say, ‘Look, this school’s got to ban junk food’?
Now, look, I’m not getting into bans. I think there’s a lot we can do working with people in obesity in the first place.
I want to change now and ask about what happens when people get sick and need to see a specialist?
Sure.
You’ve been saying more Kiwis are getting elective surgery and faster.
That’s right, yeah.
Is that right?
Yeah, they are, absolutely. So we’re doing 50,000 more operations per year than when we came into government, 60,000 more surgical specialist appointments and 50,000 more general medical appointments with the specialists, and that’s what we’ve done.
Yeah, but what you’re not taking account of in those figures there is when patients are referred to a specialist then bounced back to a GP for whatever reason, because this actually happens quite a lot. We’ve got the figures here that show 160,000 people over five years.
Well, no, there isn’t any clarity around the figures, and we are the first government ever to start counting this, so later next year we’ll have a true picture of the referral pathway. But the only thing we can say we do more appointments, more operations.
What we’ve got here is an admission we don’t have a clear picture of what’s happened to 160,000 people who have been bounced back.
And that’s why we’ve got this major work underway counting that and understanding it.
Because doesn’t something need to be done to fix this? You’ve got a 160,000… who knows what?
No, absolutely, and so what we are doing, we’re actually getting that information about it. Look, that figure – what proportion of those were referred inappropriately? What proportion are better managed in primary care? We’ll have a full understanding.
You have been proud that National’s boosted money for health, but let’s look at it this way. When you allow for inflation and population growth, is the budget under National higher or lower since you came into power?
It’s definitely higher. We’ve added $4 billion to it, so it’s gone from 11.9 to 15.9. Our opponents would argue— they want more money in there, right, but their only answer is put more money in, but they’ve never looked at how that money is being spent. We’ve put more money in, but we’re also getting better results, so free doctor’s visits, the A & E targets, the immunisation targets, more operations, five and a half thousands more doctors and nurses. We’re focused on results.
And nobody is arguing that you haven’t put more money in.
Yeah.
But what my question was, was whether if you take into account population growth and inflation – real terms is what we’re talking here – is what National’s put into health higher or lower?
Look, we’ve kept up with population growth and most inflationary pressures,…
Most.
…but what we’ve had a real focus on, okay,…
Yes.
…is the quality of the spend, and there was a lot of money wasted under Labour. And, as I say, when Annette King was the minister, the budget doubled, but she was doing fewer operations.
Yeah, but look at this real terms again, because Labour’s Infometrics report, which I’m sure you’re familiar with, showed, actually, when you take into account population growth and inflation, there’s a $485 million shortfall. Do you agree with that that you’re not keeping up with inflation and population in real terms?
Yeah, it is keeping up. Yeah, look, overall it is keeping up, right?
So that information, that—
It’s keeping up with demographics.
That Infometrics report is wrong?
What they’re saying is they were extrapolating Labour’s spending track. Now, if we’d kept up with Labour’s spending track, yeah, there would have been much, much higher levels of debt over time. It’s not about the total level of spending; it’s about what you spend the money on.
All right, Minister, that’s a good place to leave it.
Thanks very much, Patrick.
Thank you very much.
Good. Yeah, thanks. Cheers.
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