Food, Farming and Countryside Commission

Good food for flourishing communities

10th October 2018

Food, Farming and Countryside Commission roundtable discussion paper, October 2018

This paper is the result of a roundtable discussion that took place in August 2018 at the RSA on the theme of ‘Food and Farming: health and wellbeing’. The discussion formed the basis of our thinking about which policy levers could affect food, farming and trade to have the biggest effects on public health, as well as how to maximise the public health benefits of initiatives already in place (e.g. by improving procurement or increasing public access to the countryside and green space). Combined with insights gained from the bike tour and call for ideas, this paper helps to show how we arrived at the content of our progress report, and in particular the proposals in Chapter 4: ‘Good food for healthy and flourishing communities’.

Introduction

What we eat, how we eat it and where it comes from generates heated debate, particularly in relation to the nation’s health and wellbeing. However, the evidence reveals certain patterns that are concerning in terms of health and public policy. The food we eat is contributing to disease and shortening many people’s life expectancy through heart disease, diabetes, and obesity-related illnesses. Moreover, the science about what comprises a healthy and sustainable diet is evolving, and our knowledge of the micro-biome and micro-pollutants is growing.

How food is produced also has effects our health, through pollution of water and air; and through overuse of antibiotics in some forms of livestock farming. Our food system is a major contributor to greenhouse gas emissions that cause climate change, which itself has a major impact on our health and the ability of the planet to feed us well and securely.

The impacts of these changes are unequally distributed through society. While diet-related diseases are driven by over-consumption of unhealthy and highly processed food and unhealthy food environments, the dramatic rise in the UK of emergency food banks, food poverty and hunger in the last five years should also be a cause for concern. Plenty and scarcity exist side by side due to inequalities in wealth and food access. The UN estimates that 8.4m people in the UK live in food poverty. Taken together, such considerations are now challenging the prevailing wisdom about efficient and sustainable food production and how we should grow, process, sell and distribute food.

Health and wellbeing in agricultural policy

Agricultural policy can affect the food we eat and how it is processed and distributed — which in turn can cultivate better health. This has led health advocates to call for public health to be more formally recognised as a beneficial outcome from agriculture, and hence to qualify for public support in payments and policy. The concept of public money for public goods in natural capital terms (public goods such as clean air and soil water storage) has been strongly argued for by many and definitively entered the Defra policy making sphere. It is likely that future agricultural policy will in some way reframe the subsidy system so that public money is used to pay for public goods. Which public goods and how the system will be structured and administered is still unclear, but the potential shift from a production-oriented focus to agriculture, with subsidies used to increase yields, to one focused on public goods could be hugely significant. — although confusingly (and incorrectly) the Health and Harmony report lists ‘promoting agricultural productivity’ as a public good.¹

Several organisations (including Sustain, the Royal Society for Public Health, and the Food Research Collaboration), have been pressing for UK policy-makers to widen the definition of ‘public goods’ so that it includes public health, or at least in some way acknowledges that agricultural policy has the potential to both support as well as undermine public health. This debate is important and has been a long time coming. In a collection of papers titled ‘Integrating public health with European food and agricultural policy’² and published in 2004, several authors make the case for including public health in an integrated (European) agriculture and food policy. It seems obvious enough that since agricultural policy has an influence on what and how food is produced and sold, it is also a key determinant for what people eat. Studies have also shown that poor diet is a behavioural risk factor that has the highest impact on the budget of the NHS and that positive population level changes in diet would have major budgetary implications by saving the NHS billions of pounds a year.³ A 2004 Treasury report ‘Securing good health for the whole population’⁴ mentions these wider determinants of health, and is worth quoting at length from given how topical it still is 15 years later. Although the report states that “individuals are ultimately responsible for their own and their children’s health” it also goes on to say that:

“People need to be supported more actively to make better decisions about their own health and welfare because there are widespread, systematic failures that influence the decisions individuals currently make. These failures include a lack of full information, the difficulty individuals have in considering fully the wider social costs of particular behaviours, ingrained social attitudes not conducive to individuals pursuing healthy lifestyles and addictions. There are also significant inequalities related to individuals’ poor lifestyles and they tend to be related to socio-economic and sometimes ethnic differences. These failures need to be recognised. They can be tackled not only by individuals but by wide ranging action by health and care services, government, — national and local, media, businesses, society at large, families and the voluntary and community sector.”

Interestingly, as Tim Lang points out in his paper ‘European agricultural policy: Is health the missing link?’,⁵ health considerations were very much in mind when EU Common Agricultural Policy (CAP) mechanisms were first developed, after all, CAP emerged in the post war reconstruction period when European populations suffered from food shortage, rationing and a weak farming infrastructure. Under-consumption and the secure supply of food were key concerns which CAP sort to address by raising production and increasing security of food supply. But food policy has since shifted considerably to focus on using open markets to trade food (buying food on the world market is cheaper) and on individual and household responsibility rather than national food security. Environmental concerns about the impact of food production have begun to be taken on board by governments and policy makers, as have some elements of the crisis of diet-related disease and the wider impacts of our current food and agriculture system on public health. Little has been done systemically to tackle food poverty and improve health for everyone.

The links between health and food and agriculture are working their way onto the farm policy agenda. Defra nods to this in the title of their consultation report ‘Health and harmony: the future for food, farming and the environment in a Green Brexit’,⁶ although in reality most references to health are to soil, plant and animal health, with only a few to human and public health. There are some references to the wider impact on public health of animal health (due to the increase of antimicrobial resistance), and the public health benefits of access to the countryside, but no reference to diet, over or under-consumption or malnutrition, or to the concept of ‘healthy and sustainable diets’. In speeches, secretary of state for the environment, food and rural affairs Michael Gove has spoken eloquently about the need to include the public health dimension in future policy, but the proof will be in the agricultural bill pudding:

“I want to ensure we develop a coherent policy on food — integrating the needs of agriculture businesses, other enterprises, consumers, public health and the environment… As well as thinking about how our interventions to support food production currently affect the environment, we also have to consider the impact on the nation’s health…I have a responsibility to ask if public money supporting food production is also contributing to improved public health.”

Michael Gove, ‘Farming for the next generation’, January 2018.⁷

Farming for health

So what might ‘farming for health’ look like? One of the most mentioned approaches would be to incentivise fruit and vegetable production (horticulture). Although this alone would not be enough to solve the crisis of chronic disease, it can be seen as an easy win with wide benefits. Linked to supporting and increase in production (and therefore consumption) of fruits and vegetables, is the need to take a whole food chain approach to driving out excessive calorie consumption. At one level, it is clear that extra fruit and vegetables will not solve this problem. But they are an example of a win-win, with benefits to both health, environment and the rural economy (supporting smaller horticulture producers). More production alone doesn’t mean cheaper fruit and vegetables necessarily, but there are ways of stimulating the market — for example with procurement contracts that stipulate that UK fruit and vegetables should be sourced.

Another element of farming for health would be to remove the barriers to agroforestry and support more tree crop production. This might include growing more nut crops as part of agroforestry systems, but also planting more fruit and nut trees on streets — health food for everyone. The idea of healthier spaces ties in with the ideas of health and dietary diversity. Clearly, agricultural diversity leads to dietary diversity. But what in particular drives agricultural diversity? There has been little research on this that has successfully unpicked the effect of subsidies on dietary outcomes, partly because a lot this kind of macro-level analysis of cause and effect is difficult to untangle. It may be the case that market drivers may have a stronger impact on agricultural diversity than the subsidy regime. More scrutiny of these links may help to deliver the evidence needed to encourage a greater dietary diversity through farming practices and, in the medium term, offer a way of tackling food security in the face of climate change.

Farming for health also means making greater efforts to help livestock farmers transition to higher welfare and lower antibiotic usage systems and for all farmers to adopt production techniques that reduce pollution and pesticide use. Stronger legislation to reduce pesticide use could stimulate innovation by encouraging farmers to find more efficient and ecological ways of farming. What is important is to set out a clear framework or trajectory specifying long-term goals and allowing for innovation to develop within those limits. Currently, common objectives with a long-term view are absent so that frameworks for pesticide reduction (for example) are at the whim of whoever is in government at the time.

Infrastructure, investment and R&D

A key component of a healthy food system is one with adequate local food infrastructure and distribution systems which allow for fresh, nutritious and sustainably grown food to be more affordable and accessible to local communities. Health is not only about what is produced or eaten but about the delivery systems that enable everyone to have access to healthy food.

The infrastructure dimension has come to the fore in the last year with discussions about the need to support the development of local abattoirs (and the need to protect those that are in danger of closing) as well as the infrastructure associated with them.⁸ Another aspect of infrastructure that needs further investment is local food infrastructure (and distribution) to make fresh, health, sustainably grown food more affordable and accessible to local communities.

Investments in food and farming need to be re-examined because changing how investment portfolios support healthy food and farming are key. Food companies are growing so fast on the back of increased calorie consumption, focusing on a high volume, low profit margin model. This means more consumption and more waste. Might there be a way to encourage a shift to a model that creates lower value of high quality food but increases the profit margins?

For R&D, some of the research that is needed dovetails with other proposals such as reducing antibiotic use. Policies that would help transition from the currently high levels of antibiotic and pesticide use would mean new ‘integrated pest management’ approaches to farming and require innovation across the board. Other research is needed to help shift from plant breeding for storability and shelf-life to a focus on the nutritional benefits of food and breeding plant varieties for their nutritional value. This shift would also include breeding for pest resistance (to reduce pesticide use), including more legumes in plant rotations, and a R&D focus on growing more plant proteins.

Public health as public value

Since the Brexit referendum, much of the discussion about including public health in food policy has been around adding it to the list of ‘public goods’. There has been some recognition though that the term ‘public goods’ tends to be understood by HM Treasury in particular in its narrower economic theory sense as a ‘non-excludable’ and ‘non-rivalrous’ good, one which everyone can benefit from without reducing the availability to others. This contrasts with the broader public understanding of the term as ‘something that benefits the public’. In the recent seminar ‘Public health as a ‘public good’ from agriculture’ organised by Sustain, RSPH and the Food Research Collaboration,⁹ a number of interventions were made to point out that although Ministers like Michael Gove may appear to engage with the idea of public health as a public good, in practice Treasury and Defra economists were pushing back against this semantic expansion. An understanding emerged that in the current climate, the ‘public good’ definition might work more easily for some issues such as preserving antibiotics efficacy, or stewardship of clean air and water through reduced pesticide use; but might be harder to argue for where there are more complex considerations such as influencing consumption of healthier diets. For these latter, there was a suggestion that a wider ‘public value’ approach might be helpful.

So the question arises, how do we incorporate both ‘public health as a public good’ and ‘public health as a public value’ from agriculture — to ensure that public health outcomes, as well as environmental ones, are taken into account in any food, farming and countryside related policy decisions? HM Treasury is concerned with ‘public value’ which is about how public money is turned into beneficial results for citizens, aligning public resources more effectively, and improving productivity in the round — not just on farm. The public’s health and wellbeing is a central part of that conversation. So one route to finding the ‘bridging conversations’ is to broaden or shift the concept of public goods and talk as well about public values.

What are public values? Generally, public values relate to the public sphere (they are not about someone’s personal interests). A useful definition includes two elements. First, they are ‘what the public values’. But crucially, they are also “what adds value to the public sphere”.¹⁰ Public value is consumed collectively and includes public goods. But it is more than just public goods. A public values approach would include a process of defining value in collaboration with the public. Public value is delivered when there is an emotional connection through the outcomes of interventions matching up closely with the concerns of the community (at various levels from individual to local and national). In the public health realm, this means that not only could public money be used to increase public value, but the public would be ‘co-contributors’ towards their own health outcomes, as a result.

Enforcing existing legislation

There is some precedent for this via the Social Value Act of 2013. This is one of the most under-implemented pieces of legislation available to us. This requires that people who commission public services think about how they can also secure wider social, economic and environmental benefits. If, for example, government buying standards (which include sustainability) were enforced through the Social Value Act, this alone would have a huge impact on health. Similarly, within schools and the NHS, the Social Value Act could be an enabling mechanism to help promote health outcomes — and public value — over business interests NHS commissioners could work with local public health and adult social care commissioners to consider how services might maximise public value. As a participant in this roundtable put it:

“We need to show that it is an investment, with a positive return, and not just a cost. We need to use some of the tools we already have and make people aware of the power they already have to effect change”.

There may even be a case for using legal means to ensure that legislation is enforced. Just as there is a ‘Client Earth’ — lawyers who work to defend and protect natural resources by legal means — perhaps there is a case to be made for a Client Earth for Health Policy, in other words, an organisation that works to protect the public’s health by legal means.

Procurement

Enforcing the Social Value Act is linked to procurement, which is also a significant lever in promoting public health and good food provision. Currently, the NHS is one of the largest buyer of food in the country. Many NHS actors — e.g. hospitals — are already procuring food with high environmental and welfare standards, but this isn’t happening everywhere. There are of course difficulties related to changes in the retail structure — which, for example, make it harder to source locally and on a smaller scale. But the fact that public procurement works well in some places and not in others indicates that this has more to do with local level knowledge than it being a systemic or structural issue.

The low wage economy

The OECD recently indicated that the UK had the weakest wage growth of any G7 country over the last decade. The report recommended that the UK should put “greater policy effort to ensure that all workers are provided with opportunities to develop, maintain and upgrade their skills…to avoid becoming trapped in low-wage. Low-quality jobs and joblessness”.¹¹ The ‘dog eat dog’ economy of low wages and very low margins — which is particularly the case in the food and farming sector (but also elsewhere), means that Tesco staff are using food banks in Tesco and too many people are on zero hour contracts. Raising the minimum wage can help with productivity and reducing inequality as long as this is ratcheted up gradually over time in a slow and predictable way. In France, high wages have gone hand in hand with higher levels of automation. As one participant in the roundtable discussion put it: “we need to reframe the mindset that it’s impossible to increase wages and also increase profitability”.

Not only do we need to rethink how low wages are tied up with issues of inequality and productivity, we need to also understand that we (through the government) are essentially subsidizing a low-wage economy through benefits and tax credits, and therefore shifting the burden of responsibility from the private sector to the public sector. Instead, we need to enforce the minimum wage and make it unacceptable to have low paid jobs. This can be done by taking a tougher line on the pay issue — businesses will adjust when the material facts and conditions around them adjust.

Social determinants of health and food justice

It is widely acknowledged that social and economic circumstances have a huge influence on health outcomes. As the Marmot Review put is: “There is a social gradient in health — the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health.”¹² Social determinants of health include income, education, employment and working conditions, early childhood development, food insecurity, housing and social exclusion/inclusion. They also include environmental conditions such as agriculture and food production, and the quality of water and sanitation.

Attempts have been made to tackle socioeconomic inequalities in health. England became the first European country to pursue a policy to reduce them with the Labour government of 1997 by using 12 headline indicators (e.g. life expectancy, infant mortality, etc.) and departmental commitments. But by 2010, when a change of government scrapped the programme, only half of the headline indicators had been achieved and most indicators had in fact worsened. A study last year found that people in northern England are 20 per cent more likely to die before the age of 75 than those in the south.¹³ Other statistics on the BMA website are just as shocking: obesity prevalence for children in reception year at school living in the most deprived local authorities in England is more than double that of children living in the least deprived areas; and in Wales, men living in least deprived areas can expect to live nine years longer and women seven years longer than those in the most deprived — with similar trends existing across the UK.¹⁴ For all the efforts to tackle the social determinants of health inequalities, the picture is getting progressively worse. And most shocking of all is that “modifiable rick factors now account for over half the disease burden in later life”.¹⁵

Clearly action on health inequalities is still urgently needed, with better access to healthier food playing its role. This was identified in the Wanless report ‘Securing Good Health for the Whole Population’¹⁶ published in 2004 which stated that:

The key threats to our future health such as smoking, obesity and health inequalities need to be tackled now. Where the evidence exists on how to do this cost-effectively, it should be used; where it does not, promising ideas should be piloted, evaluated and stopped if the evidence shows that to be appropriate.

As with many other policy realms, health inequality needs an integrated approach that tackles a wide range of linked indicators. As the Marmot Review explained:

“Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health. Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.”

To reduce health inequalities, Marmot Review highlighted six policy objectives:

1. Give every child the best start in life

2. Enable all children, young people and adults to maximise their capabilities and have control over their lives

3. Create fair employment and good work for all

4. Ensure a healthy standard of living for all

5. Create and develop healthy and sustainable places and communities

6. Strengthen the role and impact of ill-health prevention

All the objectives are linked, and better food and farming policy could play a big role in achieving them. This would require a radical and practical overhaul of our food and farming system that would have positive impacts far beyond the borders of farms. Evidence shows that good food in childhood and healthy nutrition for pregnant women (1 and 2) helps to influence health and food choices throughout life, and to improve educational outcomes. Good work in food production and food service (3) could improve the health, well-being and ability to buy good food for the 3.9 million people in the UK who work in the food sector; and healthier food environments (4, 5 and 6) could all contribute to a shift in food quality, access and expectations across the social gradient (more on this later).

Although it isn’t clearly spelled out, one key to ‘improving the food environment’ is improving household food security. A survey carried out by the Food Standards Agency last year indicated that around 8% of adults (4 million) in the UK struggle to put food on the table with one in four low-income households struggling to eat regularly or healthily due to lack of money.¹⁷ A report by UNICEF estimated that 10% of children in the UK are living in households affected by severe food insecurity.¹⁸

The issue of food insecurity is more broadly an issue of food justice. By this is meant an issue that encompasses social, environmental and economic justice. As with social justice, food justice relates attempts to mobilise communities to tackle inequalities in the food system and highlight the disproportionate difficulty experienced by low income and minority communities in accessing healthy food. Key to a food justice approach is the focus on systemic change that understands that inequalities rooted in race, gender and class lie at the basis of lower health, economic and social outcomes. Food justice and the ‘social determinants of health’ approach are two sides of the same coin.

The most significant attempt to address the root cause of food insecurity and bring the issue of food justice and health inequality right to the fore, has been Scotland’s ‘Right to Food’ campaign. The right to food is the individual and collective right to accessible, adequate and available food. It is part of international human rights law that the UK Government signed up to in 1976 but has never created a domestic law to put it into effect.¹⁹ After several years of campaigning, the Scottish Government is currently working on a Good Food National Bill that may include incorporation of the ‘right to food’ in its wording. This would be an important step towards tackling health inequality and mean that social security reforms could be legally locked if they risked exacerbating problems of food insecurity. It would also provide a framework for accountability of the many agencies and authorities who would need to act, to ensure that food is safe, nutritious, available to all and affordable, through a combination of reducing everyday costs, boosting income and removing barriers. Sustain is now working with Just Fair and the Institute for Health and Society at the University of Newcastle to explore how a ‘right to food’ framework could be adopted into UK law.

Another legislative approach has been the Welsh Well-being of Future Generations Act 2015. This act means that public bodies need to think about the long term and sustainability impacts of their actions, co-operate with communities and businesses, and consider all aspects of well being (social, economic and environmental) in their decision making. Perhaps something similar could be implemented in England and the other devolved nations?

Given the backdrop of rising health inequality and food poverty, it is crucial that we start making the connections between the myriad indicators listed as ‘social determinants of health’ including food security, food justice and related issues of employment and housing among others. While the ‘Right to Food’ by no means solves the problem, it is a significant step in a better direction. Fundamentally though, given that the indicators listed above are dealt with by separate government departments, what is desperately needed is cross-departmental joined up thinking. As one contributor to the ‘Call for ideas’ wrote:

The best example of lack of cross department thinking is obesity and diet-related illness. Health, education & Defra need to be joined up. There are huge health savings and great environmental opportunities if we could educate people to live healthier lives, diet and exercise.

This joined up thinking needs to link government policy under austerity — particularly the policies which have induced or exacerbated inequalities (which are now enormous), and the fact that a large number of people don’t have enough money to eat well. Recent research published by the Food Foundation shows that almost 4 million children in the UK live in households for whom a healthy diet is increasingly unaffordable, that over 14 million households (half of all households in the UK) don’t spend enough on food to meet the cost of the Government’s own recommended Eat Well Guide, and that widening inequality is leading to higher rates of childhood obesity in deprived areas.²⁰ Current government policy on food and farming does not account for either planetary boundaries²¹ or the health of individuals: the links are not being made between the production system, the food system and health.

One example of an easy policy win would be reducing antibiotic use in food production given the significant implications this would have on other parts of the system. Another example would be to implement a similar approach to the US food voucher scheme which, as part of the US agriculture bill, gives food vouchers to low-income families that must be spent in farmers’ markets. According to one participant of the roundtable, this has been show to reduce the cost of fruit and vegetables by 30% and increase consumption by 27%.

Food in schools

Discussion about low wages, health inequalities and food justice is linked with conversations about schools. Given that everyone goes to school (rich and poor) and school is the place where skills are influenced, this is the place where programmes like ‘Food for Life’ can have (and do have) such a huge positive impact. Currently, free school food is available for 4 to 6 years old, but making healthy food available for the whole population would be a significant way of improving health inequalities. Children in Food for Life schools have been shown to be twice more likely to eat 5-a-day than children in ‘normal’ (non-FFL) schools. Rolling out this sort of programme more widely would have significant positive impacts. It is harder to improve hospital foods than school foods partly because hospitals often need to retrofit kitchens which is complicated — although many improvements to catering can still take place.

There is also a wider conversation to be had about food and health education broadly — teaching children to grow and cook food, but there was a general sense in roundtables and through the Call that although important, more radical and innovative initiatives could be developed beyond the almost clichéd ‘improve cooking skills in schools’ approaches. These other approaches could include: supporting children in schools to pay for transport/trips to the countryside or to projects that emphasise food and farming experiences; making schools more nature friendly (nature schools); supporting more farm visits by schools; twinning every school with a farm (on the back of the success of Open Farm Sunday); and by giving permission for the pupil premium to be used on farm visits.

Green care

As highlighted in the Marmot Review, a policy objective that would have a significant impact on health inequality would be to improve the availability of ‘good quality open and green space across the social gradient’. A 2016 study by Natural England found that 12 per cent of children had not walked in a park, forest of natural environment in the previous year.²² The figures were even starker for children from low income and black, Asian and minority ethnic families (BAME): 56 per cent of under-16s from BAME visited the natural environment at least once a week compared to 74 per cent of children from white households.

There is increasing evidence now that environmental initiatives such as woodland planting and trees for urban spaces have been linked to physical and mental health outcomes both in terms of access to urban green spaces (with benefits to mental health), the positive impacts of walking in woodlands specifically (rather than just the countryside as a whole), as well as cleaner air and cooler cities. A 200-page report commissioned by Defra and CLG in 2010 comprehensively lists the economic, social, environmental, land regeneration, and hydrological benefits of ‘green infrastructure’, which they define as “the combined structure, position, connectivity and types of green spaces which together enable delivery of multiple benefits as goods and services.”²³ Social benefits include improving levels of physical activity and health, promoting psychological health and mental well-being, and the facilitation of social interaction, inclusion and community cohesion.

Some of these benefits were mentioned by contributors to the ‘call for ideas’. One of them mentioned that:

“The potential for Forest Gardening can be overlooked as it falls in the space between commercial agriculture and horticulture/gardening. It has benefits (i.e. to mental health and wellbeing) beyond those normally associated with growing food.”

This theme appeared multiple times across the submissions we received with another contributor writing about the importance of increasing “opportunities to help people get back in touch with nature, which we know is so good for physical and mental health”. Currently less than 1 in 5 people regularly use outdoor space for health or exercise.²⁴

One approach to harnessing the benefits of contact with green spaces has come to be termed ‘green care’. This is an umbrella term that includes a wide range of health-promoting interventions that use interactions with nature, or are linked in some way to a natural environment, as part of their treatment. In the UK, green care has largely taken the form of care farming,²⁵ horticultural therapy and green exercise. Fundamentally, green care lies somewhere in the cross over between traditional healthcare and activities within agriculture, gardening, natural conservation and animal husbandry among others.

A study on care farming in the UK, found that although there was still limited acceptance of the role that care farming could play in health from healthcare and social service providers:

“Evidence from both Europe and the UK has demonstrated that care farming is a win-win situation for farmers and rural communities, allowing the farm to stay economically viable, the farmer to continue in agriculture and chance to provide a health, social rehabilitation or education service for the wider society. Care farming represents an example of multifunctional agriculture and offers a way to recognise the variety of different public goods and services our farms provide rather than simply focusing on food production, thus deriving extra value from the land.”

Given the obvious benefits of access to green space and contact with the natural world, there has been increased interest in social prescribing associated with green care.

Social prescribing

The NHS defines social prescribing as:

“A means of enabling GPs and other frontline healthcare professionals to refer people to ‘services’ in their community instead of offering only medicalised solutions…The community activities range from art classes to singing groups, from walking clubs to gardening, and to many other interest groups.”²⁶

In England, nearly half of all clinical commissioning groups have invested in social prescribing programmes, with 1 in 5 GPs referring patients to social prescribing. A review of the impact of social prescribing demand within the NHS found that although the evidence for social prescribing was broadly supportive of its potential to reduce demand on primary and secondary care (and thereby reduce burden on the NHS), the quality of the evidence was weak. The study points out that one of the reasons social prescribing has grown (despite the lack of evidence) may be “the effect that social prescribing reportedly has on the health and wellbeing of patients. The social prescribing narrative is compelling and much of the qualitative evidence shows that these services are very well liked by patients and GPs alike”.²⁷

Another study which also found that the evidence for social prescribing was weak concluded that “current evidence fails to provide sufficient detail to judge either success or value for money. If social prescribing is to realise its potential, future evaluations must be comparative by design and consider when, by whom, for whom, how well and at what cost.”²⁸

There is clearly scope for social prescribing to be linked to food and farming with potentially positive impacts on public health, as well as potential cost savings for the NHS. There are at least three ways in which food can be integrated into health-promoting social prescribing:

  1. Food growing — therapeutic gardening, care farms, horticulture;
  2. Food making — sociable cooking and eating; healthy eating classes for healthy; lifestyles and disease management; and
  3. Food access — supporting community initiatives to improve and increase access

There is now increased evidence of the benefits of this sort of work on community cohesion, the local economy, the environment, and mental health.[iii] The challenges are now more structural and about building this sort of social prescribing into commissioning, as well as improving the preparedness of both the health service and care farms to work in this way. The one important caveat to make to all this is to ensure that social prescribing isn’t used as way of simply devolving responsibility for health to individuals (and the community) as a cost-saving measure.

Additional points

Although climate change has come up in the bike tour, ‘Call for Ideas’ and various roundtables, this has mostly been in the form of “we need to talk about climate change” with little detail. Despite the obvious urgency of dealing with climate change and the enormous repercussions it is already having on the food system globally and here in the UK — let alone on public health, global security, migration, and more — policy discussions have tended to focus on more visible and immediate problems. Part of the lack of action is the sense that because the impacts of climate change are manifold and global, regulation needs to happen at a global inter-governmental level. What has been clear from discussions with roundtable participants and others in the commission process, is that multinational companies need to be regulated and the government held to account. Just as the Social Value Act 2012 needs enforcing, so does the Climate Change Act 2008.

Finally, another point worth mentioning was the importance of hope, beauty and aesthetics. One person in roundtable discussion put it succinctly: “If a system of sustainability isn’t generating hope, then it’s something missing.” The words aesthetic and beauty come up a lot, but perhaps they need to be reframed as ‘wilderness’ or something similar. The process by which we frame these processes and the way we engage key stakeholders with them is crucial to the longevity and success of these ideas.

Conclusion

This discussion paper has touched on a number of key themes that meet at the intersection of food, farming and public health. The Ideas generated throughout the paper emerge directly from the roundtable discussion with supplementary material provided through the Call for Ideas and bike tour interviews and encounters. It is clear that we face huge challenges over the coming years to create a food and farming system that acknowledges its public health role and responsibility. There are a large number of areas of discussion and policy making, from children’s health and schools, to the role of the state in improving procurement, and legislating and enforcing laws that improve the impact of food and farming on public health. Many of the themes covered in this discussion paper overlap with each other and therefore highlight the interconnected nature of policy and intractability of these problems if we continue to face them with a siloed approach to policy making.

In summary, the main areas for policy intervention outlined in the discussion paper are as follows:

  • Support more fruit and vegetable production, contributing to more affordable, healthier diets.
  • Remove barriers to agroforestry and support more tree crop production.
  • Help livestock farmers to make the transition to higher welfare, lower antibiotic and pesticide use; and to for all farmers to adopt production techniques that reduce pollution.
  • Invest in local food infrastructure and distribution to make fresh, healthy food, sustainably grown food more affordable and accessible to local communities.
  • Shift from considerations of public goods to public value by defining value in collaboration with the public.
  • Move to ensure that existing legislation — such as the Social Value Act and Climate Change Act — is properly enforced.
  • Increase the minimum wage gradually over time to tackle the low-wage economy, reduce inequality, and boost innovation.
  • Develop new approaches to food and farming education in schools.
  • Increase social prescribing and green care as a means of positively impacting public health, as well as offering cost savings for the NHS.

Next steps

There appears to be a clear appetite for strong government intervention in the food and public health arena — witness the success of the sugary drinks tax — particularly when it comes to safeguarding children’s health and that of future generations. Given the continued rise of diet related diseases (see recent news of the rise of type 2 diabetes among young people) there is some hope (and we need to generate hope) that the Overton window may have opened a little more.

We will be commissioning research about how to take some of these ideas further, to ensure that we develop proposals which maximise the public health benefits of food, farming and access to the countryside.

Endotes

[1] Defra (2018) Health and Harmony: The Future for Food, Farming and the Environment in a Green Brexit (Department for Environment, Food & Rural Affairs). Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684003/future-farming-environment-consult-document.pdf.

[2] Eurohealth (2004) Integrating Public Health with European Food and Agricultural Policy, LSE Health and Social Care. Available at http://www.lse.ac.uk/lse-health/assets/documents/eurohealth/issues/eurohealth-v10n1.pdf

[3] Scarborough, P. et al. (2011) The Economic Burden of Ill Health due to Diet, Physical Inactivity, Smoking, Alcohol and Obesity in the UK: An Update to 2006–07 NHS Costs, Journal of Public Health (Oxford, England), 33(4), pp. 527–535.

[4] Wanless D. Securing good health for the whole population. Report to the Prime Minister, The Secretary of State for Health and the Chancellor of the Exchequer. London, UK: HM Treasury on behalf of HMSO, 2004

[5] Lang, T (2004) European agricultural policy: Is health the missing link? Integrating Public Health with European Food and Agricultural Policy, Eurohealth: LSE Health and Social Care. Available at http://www.lse.ac.uk/lse-health/assets/documents/eurohealth/issues/eurohealth-v10n1.pdf

[6] Defra (2018) Health and Harmony: The Future for Food, Farming and the Environment in a Green Brexit (Department for Environment, Food & Rural Affairs). Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684003/future-farming-environment-consult-document.pdf.

[7] Gove, M (2018). Farming for the next generation. Available at https://www.gov.uk/government/speeches/farming-for-the-next-generation

[8] Sustainable Food Trust (2018). A Good Life and a Good Death: Re-localising farm animal slaughter. https://sustainablefoodtrust.org/articles/a-good-life-and-a-good-death-re-localising-farm-animal-slaughter/

[9] Food Research Collaboration (2018). Public health as a ‘public good’ from agriculture. How can we win support for this principle from UK policy makers? Public seminar. Available at http://foodresearch.org.uk/event/public-health-as-a-public-good-from-agriculture-how-can-we-win-support-for-this-principle-from-uk-policy-makers/

[10] Benington, J. (2009) Creating the Public In Order To Create Public Value? International Journal of Public Administration, 32(3–4), pp. 232–249.

[11] Financial Times (2018). UK wage growth weakest in G7 since financial crisis. https://www.ft.com/content/c4437c9e-7ec4-11e8-bc55-50daf11b720d

[12] Marmot, M., Goldblatt, P., Allen, J. et al. (2010) Fair Society Healthy Lives (The Marmot Review). Institute of Health Equity. Available at http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

[13] Buchan, I. E. et al. (2017) North-South Disparities in English mortality1965–2015: Longitudinal Population Study, J Epidemiol Community Health, 71(9), pp. 928–936.

[14] BMA (2018) BMA — Health Inequalities. Available at https://www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/health-inequalities, accessed July 25, 2018.

[15] The Richmond Group of Charities (2018) Destined to ‘sink or Swim Together’: NHS, Social Care and Public Health (The Richmond Group of Charities). Available at https://richmondgroupofcharities.org.uk/sites/default/files/final_aw_5902_the_richmond_group_a4_10pp_report.pdf.

[16] Wanless, D. (2004) Securing Good Health for the Whole Population (HM Treasury). Available at https://tinyurl.com/ycr7jg2x

[17] FSA (2017) The Food & You Survey, Wave 4. Available at https://www.food.gov.uk/sites/default/files/media/document/food-and-you-w4-exec-summary.pdf

[18] Pereira, A., Handa, S., Holmqvist, G. (2017) Prevalence and correlates of food insecurity among children across the globe. Unicef. Available at https://www.unicef-irc.org/publications/900-prevalence-and-correlates-of-food-insecurity-among-children-across-the-globe.html

[19] Nourish Scotland (2018). Right to Food. http://www.nourishscotland.org/campaigns/right-to-food/

[20] Scott, C., Sutherland, J., Taylor, A. (2018) Affordability of the UK’s Eatwell Guide. Available at https://foodfoundation.org.uk/wp-content/uploads/2018/09/Affordability-of-the-Eatwell-Guide_Final_Web-Version.pdf

[21] Stockholm Resilience Centre (2018). Planetary Boundaries. Available at http://www.stockholmresilience.org/research/planetary-boundaries.html

[22] Natural England (2016) MENE: A Pilot for an Indicator of Visits to the Natural Environment by Children (Natural England). Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/498944/mene-childrens-report-years-1-2.pdf.

[23] Forest Research (2010). Benefits of green infrastructure. Report to Defra and CLG. Forest Research, Farnham. Available at http://www.sustainabilitywestmidlands.org.uk/wp-content/uploads/Benefits_of_green_infrastructure_2010.pdf

[24] Public Health Profiles (2017). Utilisation of outdoor space for exercise/health reasons. Available at https://fingertips.phe.org.uk/search/outdoor%20space%20exercise

[25] Care Farming UK (2018). Available at https://www.carefarminguk.org/

[26] NHS England (2018). Available at https://www.england.nhs.uk/personalised-health-and-care/social-prescribing/

[27] Polley, M. et al. (2017) A Review of the Evidence Assessing Impact of Social Prescribing on Healthcare Demand and Cost Implications (University of Westminster). Available at https://www.westminster.ac.uk/file/113316/download.

[28] Bickerdike, L. et al. (2017) Social Prescribing: Less Rhetoric and More Reality. A Systematic Review of the Evidence, BMJ Open, 7(4), p. e013384.

[29] Schmutz, U. et al. (2014) The Benefits of Gardening and Food Growing for Health and Wellbeing (Garden Organic and Sustain). Available at https://www.sustainweb.org/secure/GrowingHealth_BenefitsReport.pdf.

.


Note: this paper was originally published on the RSA website (Royal Society for the encouragement of Arts, Manufactures and Commerce), which hosted the Food, Farming and Countryside Commission between November 2017-April 2020.