Adolescent Health

HL Deb 15 June 2004 vol 662 cc721-42

8.9 p.m.

Baroness Massey of Darwen

rose to ask Her Majesty's Government what is their response to the British Medical Association report Adolescent Health, with particular regard to obesity and sexual health.

The noble Baroness said: My Lords, I am delighted to have secured this debate. It is an important topic at a crucial time. I am most grateful to noble Lords for supporting it at such short notice and with such stamina. It is an amazing turnout. I also thank the Minister for her interest in the subject of adolescent health.

I first want to make some preliminary remarks, then focus on the BMA's excellent report and other findings about adolescent health, and finally ask the Minister to comment on the importance of research and evaluation relating to adolescent health and training. I shall not go into a plethora of statistics, but will rather discuss some broad brush ideas. I know that other noble Lords will provide different perspectives on this question.

Concerns about the health of young people are not new. I remember teaching health education in schools in London in the 1980s. Some of the issues arising then are still around; some aspects have changed—for example, the AIDS pandemic has brought new urgency into sexual health; Chlamydia is now a serious problem; obesity and its consequences have increased.

As then, adolescents are a vulnerable group—not quite adult, prone to risk taking and sometimes treated as a problem. Adolescents need positive role models and support from adults, particularly from parents. Early interventions are important and that comes largely from parents—for example, in breastfeeding and nutrition. But this issue of health is not only topic based or problem based, a great many influences feature in how people make decisions about health—their economic situation, their communities, their friends and family, their culture, the media and so on. Young people need the skills to make informed decisions; to resist pressure. They need life skills, empowerment and motivation rather than blame and unrealistic nagging.

Parents need support too. Young people are maturing earlier, their lives are more complex than they used to be and many parents are confused and threatened by the changes. Parents need to be involved in the solutions and they need education and support. Programmes such as Sure Start are providing this. I wish there was a continuous Sure Start as children grow up. One key issue which was present when I was teaching, and subsequently training teachers, was the vital importance of having sufficient numbers of trained and confident teachers to deliver personal, social and health education, including sex education, and to link with parents and to support parents and families.

I said that the issue of adolescent health was not new and numerous reports and surveys have highlighted this. For example, a BMA report in 1999, Growing Up in Britain, looked at the foundations of health in nought to five year-olds. This took into account inequalities in health, emotional and behavioural problems and nutrition, among other things. One conclusion of the report was, Good child care involves a mutually affectionate relationship based on respect, empathy and genuineness with one or preferably more adults, consistent discipline based on positive reward for good behaviour rather than punishment for bad, and intellectual stimulation based on the child's level of development". If all that happened to children, we might not today be discussing problems of obesity and sexual health in adolescents.

The report highlighted the importance of the consumption of enough fruit and vegetables and the desirability of limiting sugary foods. It also touched on the importance of sex education being embedded in an overall education programme, something which I know other noble Lords will discuss in more detail.

An excellent book by David Hall and David Elliman, Health for All children, is wide-reaching and discusses the role of families, health professionals and other health educators in influencing child and adolescent health. It emphasises the importance of strategy and policy at a national and local level and the importance of co-ordinating efforts and sharing information, something highlighted in the Children Bill currently before your Lordships' House.

The BMA report, significantly, calls for a named school nurse and doctor for each school, with access to a wider range of health support such as community nurses, paediatricians and therapists. I have said it before and I will say it again: school counsellors were useful and need to be reinstated.

The National Healthy Schools Standard, of which I am a great supporter and which features in the school where I am a school governor, is working positively with schools to encourage healthy choices in children and in communities, including an emphasis on nutrition and exercise.

The BMA report picks up and expands on many of the issues raised in previous reports and provides a number of statistics. It also summarises the grave concerns now being expressed about an obesity epidemic, which may give rise to diseases such as diabetes and heart disease, as has recently been reported in the press and other media.

Multi-factoral interventions are considered necessary to change health behaviour. The report suggests that there needs to be an awareness of issues, multi-professional interventions, early intervention, education, structural and environmental change and public health campaigns as well as, crucially, access to sympathetic services.

Noble Lords may remember, in the 1980s and early 1990s, the successful publicity from government and the voluntary sector about HIV and AIDS. Health messages need to be consistently and constantly conveyed, and constantly reinforced. It must be made easy to make healthy choices—for example, sports facilities must be accessible and encouraging.

The report also emphasises the need to make parents, children and adolescents aware of good health behaviour and to enable them to integrate it into their lives—for example, in exercise—to contribute to reducing obesity. Peer education programmes should be considered as part of health education programmes.

In conclusion, I ask the Minister to comment on the amount of research and evaluation of initiatives in the UK designed to improve adolescent health with regard, in particular, to obesity and sexual health. I am interested in, but somewhat frustrated by, a seeming reliance on American initiatives. Could I also ask if there is general agreement across government departments that confident and trained professionals and parents are absolutely key to improving adolescent health?

We neglect the issue of child and adolescent health at our peril. These adolescents will, too, become stakeholders in society; many of them will become parents. We cannot afford, materially, physically or morally, to tolerate a cycle of ill health which could spiral out of control.

8.18 p.m.

Lord Addington

My Lords, when I first decided to put my name down to speak in this debate, I was originally drawn to the part about obesity. When I heard initially that I had only three minutes, I thought that any danger of my having to mention sexual health was totally removed. However, as I have a moment more, I shall leave the Government with one thought on the second of the two topics we are discussing.

The most successful campaign on sexual health was that of the noble Lord, Lord Fowler. The reason it influenced people so much—indeed, I was one of those in my early 20s when it started—was because it permeated the whole of society. We could not get away from it. Looking at the one successful example, to get the message across one needs to permeate society so thoroughly with the message that people in their 40s, 50s and 60s become sick of hearing it and start saying, "This doesn't apply to me". In that way, the message will probably get across. When we are very young we are very good at not hearing what we do not want to hear.

That brings me reasonably neatly to the subject of obesity. The basics of obesity are comparatively straightforward. One takes in too many foodstuffs or calories and does not burn them off. There is a limit to how many calories one can burn off, but physical activity will help. I looked through the report to discover who is regarded as adolescent and concluded that it is a broad group between the ages of 11 and 18. That group experiments with spending power, with doing its own thing, with the petty rebellion of annoying parents and teachers and with looking exactly the same as their friends. The group is a rich target for advertisers not only of food and drink, but also of lifestyle. It is seen as cool to sit around drinking or to appear laid back. The only people who take part in sport are those who are brilliant at it and who look good doing it. We have to try to encourage that group to take more exercise.

The noble Lord, Lord McIntosh, said that I was being harsh when I described government initiatives as saying that adolescents should do the dishes or the ironing to get in their quota of activity. I said that that did not really address the young and the fit. Now we are addressing them. I have it on good authority that to get an adolescent to do any cooking or cleaning or ironing is an achievement in itself. We can also encourage them to do gardening, but usually, where there is a garden, it is the territory of someone considerably older. Bizarrely, as we go up the social scale the level of physical activity rises.

Sport has to be the answer, but unfortunately sport appears to be a middle-class preserve. If a young child has a bad diet and is overweight, he or she does not want to stand out in front of his or her friends so is unlikely to puff and pant around a football field. Such a child also does not want to be the last one picked for a team. Indeed, a child does not want to be involved in fights about who will have him on the team because he is felt to be a liability. We have to do something about this group and encourage them to take part.

There is a great deal of consensus across the political divide about what we should do as regards sport. Basically, there should be more sport in schools and sport in schools should be used to encourage the wider community to take part in sport. The old school structure of sport has broken down because it relied on volunteers. The upside of that is that we no longer have sports coaches who have no coaching qualifications and are 30 years out of practice in playing various sports. But we have lost the basics.

At various times all sides of the House have agreed that we have to address the problem. The Government have quite an impressive plan. I would be pleased to hear a progress report on it. I believe that all departments could be brought to bear on this and I believe that the Minister is primarily taking on a health mantle today. I see the noble Baroness nod. I have one question for her. Has the Department of Health been told exactly how many playing fields, sports halls and so on are needed to allow for the increase in sport and physical activity that would counter the rise in obesity, or at least a part of it? I believe that is a fair question to ask. The doomsday book of sport is supposed to be out soon and it would help if we had an answer to that. The argument about playing fields being sold to build new sporting facilities and the balance between having training halls but no pitches, may mean that we shall end up with fewer facilities. What do we actually need? Do the Government know? Even if the Government's idea is wrong, at least we could argue with a certainty. It is a nebulous concept in the distance at the moment.

On the issue of food intake, the great villains of the piece are the fast food merchants. Certainly, they have the highest advertising budgets. However, their role has possibly been overplayed. The high street shops sell pre-prepared meals that are easy to cook and we have bad nutritional awareness. Despite certain ex-footballers screaming and shouting at celebrities on television recently, we are not sufficiently aware of how to cook meals.

If we are to address the idea of what constitutes a balanced diet, perhaps as one not based on comfort food—and let us face it, we all like that hit of sugar, salt and fat every now and again—the Government must tell us their thinking. In particular, have they considered how we can discourage the consumption of sugary carbonated drinks? They must be the biggest teenage fix of all. The preparation for drinking far too many pints of beer is to drink too much Coca Cola, lemonade or whatever. That is what I have heard. Many doctors are speaking in this debate and I hope that I will not be contradicted.

Sugary, carbonated drinks are probably the most efficient way of getting unwanted calories. If I am wrong, I will put my hand up, but nobody has contradicted me yet. What are the Government doing to cut levels of such consumption? This is a topic that will run and run. I look forward to the debate.

8.27 p.m.

Lord Turnberg

My Lords, this speech has been lengthened and shortened so many times: I hope it remains comprehensible.

The sorts of malaises that we are discussing this evening are largely self-inflicted—due to smoking, drinking, overeating or engaging in unsafe sexual practice. They remind me of the saying, "Everything I like is either illegal, immoral or fattening". Therein lies the rub, because, although these illnesses are largely determined by one's behaviour, their prevention is dependent on persuading people to stop doing what they enjoy. Changing behaviour in anyone is not easy and changing adolescent behaviour is extremely difficult. We need only look back at the strenuous efforts that have been made over the years in the field of sexual health to realise how little impact they have made. Sexual health was one of the five priority areas in the 1992 Health of the Nation White Paper. It was also prioritised in the 1999 Welsh Assembly paper, yet new cases of syphilis, gonorrhoea and chlamydia doubled between 1995 and 2000. The evidence is that the incidence of these diseases continues to rise.

We must face the fact that health education messages are not very cool—or whatever the modern equivalent of "cool" is. They are up against the much more persuasive and effective messages of the devil, in the shape of the advertising industry, which uses sexual images lo sell everything from ice cream to motor cars. As the Chief Rabbi wrote in the Times last weekend, big business discovered that children represent an immense potential market. So began the transformation of children into consumers. To young adolescents striving to find their own sense of identity, rebellious behaviour is part of the normal process of growing up. The more that cigarettes, alcohol and sex are preached against, the more likely it is that some adolescents will take the opposite view.

That combination of adolescent behaviour patterns, the market-driven advertising media and television soaps, "Big Brother" and the like, which show how normal and acceptable careless promiscuity really is, represents a formidable opposition to health education, at least in the sexual field.

We could of course continue to wring our hands, but perhaps it might be better to cast a more critical eye on the advertising industry and seek a more responsible approach from it. Is it also a vain hope to try to press the televisual media to aim more at reflecting society's good behaviour rather than its poor behaviour? Possibly such a shift might do something for their viewing figures. Of course, I know that railing against the advertising industry and the media is a somewhat vain hope, but I had to get it off my chest.

Meanwhile, getting the message across about considerate, safe sexual practices needs some new approaches. I was particularly impressed when I visited St George's Hospital Medical School recently and met some medical students who were going out to hold meetings in clubs and out of school to talk about sensible sex to young teenagers not much younger than themselves. They were part of a national scheme rejoicing under the name of "Sexpression" run by medical students across the country.

This type of informal peer interaction is much more likely to be effective than if the same messages were to be delivered by parents or teachers. It is the sort of imaginative scheme we should be supporting and building upon. Can I tempt the Minister to look at this type of approach as one worth pursuing?

While prevention by education and behaviour change will be a slow, uphill task, we will continue to need to deal with the consequences of unsafe sex. I believe there is much that can and should be done. I want to focus on one area—chlamydia, which is a nasty and insidious disease. My noble friend Lady Gould of Potternewton will talk about that, so I shall just give a trailer.

The frequency of chlamydia has doubled in the past 10 years and now affects 10 per cent of young women. It often does not produce any symptoms at all, but the danger is that it may go on to cause pelvic inflammatory disease. That itself is a common cause of infertility and ectopic pregnancy. Yet diagnosis is easy, and a simple screening test of urine will reveal it. It can be readily cured with a short course of antibiotics. So it is much to be welcomed that the Government have embarked upon a national screening programme in primary care. Can the Minister tell us how far we have got with that?

More generally, it is also important that the Government's action plans for sexual health should be actively pursued. We have certainly been short of genito-urinary doctors and clinics, and have a history of waiting times—particularly in our cities—which are far too long. It is good to know that the Government are committed to investing in this neglected area. Can the Minister tell us what progress is being made here?

8.32 p.m.

Lord Patel

My Lords, we have already heard about problems related to teenage sexual health. There has been much publicity about the rising rates of sexually transmitted infections—most apparent in 16 to 19 year-olds—which have serious health outcomes, in both the short term and the long term. I am well aware that the Government recognise the problem and have done a lot to promote good sexual health. What I would like to find out is the success or otherwise of some of the government policies.

The Government's teenage pregnancy strategy was launched in 1999. One of the aims was to halve the pregnancy rate in under-18s by 2010. The strategy supported a range of activities to meet this target. One of them was the number of dedicated, school-based, trained teachers for sex and relationship education. Can the Minister say how close the Government are to meeting these targets, because the recent evidence is otherwise? How close are they to meeting targets of halving teenage pregnancy, and the number of trained SRE teachers in every school?

The other strand in the strategy was improving access to sexual health services. As sexual health is not included in the "essential services" of the new GP contract, what will be the future role of GPs in that? Another strand of the strategy was screening for asymptomatic infections. The noble Lord, Lord Turnberg, has already mentioned the strategy for screening for chlamydia infection, and he has asked the question on how that is working. How is the system of the opportunistic screening scheme being evaluated against other screening strategies?

If we are to avoid long-term health consequences, current policies must achieve rapid impact in the light of increasing incidence of teenage sexual health problems. As we are allowed a little more time now, I will comment briefly on adolescent mental health and mental illness.

Adolescent mental health problems have strong links with adolescent health risk behaviour such as violence, sexual behaviour, teenage pregnancy, alcohol and drug abuse. A lack of definition of mental health results in data on the incidence of mental illness coming from people who use the services or from the responses to structured questionnaires. None the less, the available data show that the incidence of the serious illness of depression is estimated at 1.7 per cent in boys and 1.9 per cent in girls. That is often associated with conduct disorder. Self-injury and self-harm, bulimia and anorexia nervosa, which disproportionately affect young girls, and result in high death rates, are further examples of adolescent mental health problems. We know from research the factors that predispose young people to increased risk of adolescent mental health problems, among which gender, age and family related factors of poverty and lone parenting are important.

Although the Government have some strategies in place such as the national suicide prevention strategy, will the Minister tell the House what other initiatives are planned, and particularly whether the children's national service framework, which is about to be published, will include standards for adolescent mental health as the current national service framework for mental health does not? What will be the role of primary care teams in identifying those at risk?

If teenage sexual health is a time bomb about to explode, we have not even begun to recognise the problems of adolescent mental health and illness and their long-term effect.

8.36 p.m.

Baroness Gould of Potternewton

My Lords, first, I thank my noble friend Lady Massey for introducing the debate and for managing to initiate it this evening. This is a very important report, covering, as it does, the correlation between the different aspects of public health.

I should start by declaring an interest as the chair of the Independent Advisory Group on Sexual Health and HIV. I shall concentrate my remarks on the sexual health aspects of the report. As I say, the report correlates different aspects of public health. It is important that we view sexual health in a holistic way. It is absolutely crucial that an adolescent's whole sexual well-being is taken into consideration when they seek advice or treatment about one specific area.

The report is right to say that the sexual health of adolescents in the UK is poor. The increase in risky sexual behaviour is a key contributor to sexual health outcomes such as sexually transmitted infections (STIs) and unwanted pregnancy in young people. Nearly three years since the publication of the first ever National Strategy for Sexual Health and HIV, for which we must give credit to this Government, we are on the verge of a major public health crisis in spite of efforts that have been made by the Government since the strategy was produced. However, there is much more to be done.

What I find really disturbing is the evidence of a drop in knowledge and a lack of awareness of the risks being taken through having unprotected sex. In 1995, for instance, 77 per cent of boys between 12 and 13 knew that HIV could be passed on by having sex without a condom. By 2002, that figure was down to 63 per cent. I read today that a survey carried out in Sheffield shows that 40 per cent of pupils aged 11 have never even heard of HIV. There are many other such examples.

However, as has been said, we must appreciate that many young people experience peer pressure. They believe that certain behaviour is considered "cool" and they receive mixed messages from the media. That, coupled with impaired decision-making due to excessive alcohol or drug taking, makes the risk even worse. Raising awareness and promoting the safer sex message is therefore absolutely crucial.

The "Sex Lottery" campaign, initiated by the Government and directed at young people, is welcome, as are schemes such as those mentioned by the noble Lord, Lord Turnberg, promoting sexual health in colleges, nightclubs, sports clubs and workplaces. He is right—we have to be more imaginative about how we promote the message. That is all fine, but there is often a lack of consistency and continuity in such campaigns, and the long-term improvement in sexual health can only be achieved by a far greater promotion of good, early, co-ordinated and appropriate sex education in schools. It is important that sex education be a statutory part of the national curriculum, with each school having an appropriately trained teacher. That is clearly not the position at present. There is consistent evidence that PSHE remains patchy, under-resourced and often delivered by non-specialist, reluctant and poorly-prepared teachers, who often do not understand the breadth and scope of the subject they have been asked to teach. Good PSHE should include the development of a person's broader life skills, such as the effects of excessive use of alcohol, drug-taking and their influence on risk-taking behaviour. Similarly, as my noble friend Lady Massey said, there must be programmes designed to educate parents and carers, so that there can be greater openness and understanding across the generations.

Good education is the key to better prevention, and prevention is the best way to resolve our growing sexual health crisis. We can give two examples in other countries where education is clearly effective. In Uganda they run the effective "ABC" campaign, where A stands for "Abstinence", B for "Be faithful" and C for "or use a Condom". In Sweden, where there has been more explicit sex education in schools and youth clinics, they have reduced teenage pregnancy by 80 per cent, and STIs by 40 per cent.

Girls are much more vulnerable to STIs. The rate of chlamydia is alarming: 36 per cent of young women with the disease are under the age of 20. That age group, for both men and women, must be a key target area for screening. Chlamydia is a preventable transmittable disease. One act of unprotected sex with an infected partner can create a 1 per cent risk of acquiring HIV, a 30 per cent risk of genital herpes and a 50 per cent risk of contracting gonorrhoea. I appreciate that the Government are moving into the second phase of the chlamydia screening programme, but we cannot wait—a national rollout is needed now. That is plain common sense. My noble friend Lord Turnberg referred to the relationship between pelvic inflammatory disease and subsequent infertility. Surely it is better to invest now in screening and prevention. It makes good health sense, but also good economic sense.

Poor sexual healthcare costs government and society dearly, so we need more investment in awareness-raising campaigns; a move towards more comprehensive and integrated services; one visit providing contraceptive advice, testing and, as appropriate, support and counselling; and improved PSHE and SRE in our schools to arm our children with the knowledge that will enable them to make informed choices about their sexual behaviour and wellbeing. Above all, we need a brave, innovative and imaginative approach to the whole question of sexual health. Only in that way will we see a dramatic reduction in teenage pregnancy levels and STIs in young people.

8.44 p.m.

Lord Chan

My Lords, I also thank the noble Baroness, Lady Massey, for securing this debate on the BMA's report on adolescent health. Although the focus has been on sexually transmitted diseases, sexual health and obesity, the report in fact takes a much more holistic approach, as has been mentioned by other noble Lords.

I shall confine my remarks to findings on Merseyside, and for this I want to thank members of the public health department of my primary care trust, of which I am a non-executive director, on the Wirral.

Her Majesty's Government have invested in the health of our young children, starting at birth and extending to the first three years, particularly in districts of Merseyside in which poverty affects most residents. The Sure Start programme, initiated three years ago, is beginning to show positive outcomes. For example, more single mothers are breastfeeding their babies and, as a result, protecting them from the later effects of becoming obese. They are also learning to feed their young children on health-promoting food, including fresh fruit, which is given out free in schools to those who need it, and vegetables. In addition, nurseries are being provided to give young children a stimulating environment.

The vulnerability of adolescents is obvious, but there seems to be no concerned programme concerned with them. In my experience, on Merseyside, where teenage single mothers represent a significant number of single parents, the problem is even more acute. We know that, through the Sure Start programme, young mothers receive support and health information of benefit to them and their young children. They are encouraged to give up smoking, for the sake of their offspring.

Apart from those indirect interventions and the focus on preventing teenage pregnancy through community services such as those provided by the Brook Advisory Centres, there is little emphasis in the NHS on adolescent health. I suspect that that omission may be based on the assumption that partnerships between local authorities and the NHS focused on teenage pregnancy can prevent sexually transmitted infections. However, the number of pregnancies among teenage women—those under 18—in England and Wales rose by 2.2 per cent in 2002 to nearly 42,000.

In the past 12 to 18 months, some Merseyside primary care trusts have commissioned the Brook Advisory Centres to provide advice on contraception and on sexually transmitted infections to anyone under 25 years of age. That service consists of a walk-in service, where contraception is given out and counselling is given to young women who think that they are pregnant. In addition, there is a genitourinary medicine clinic run for two days a week by trained nurses from the local hospital. It is located in the town centre, and we have collected some good information from it.

In the past 12 months, the service has been used 10,000 times, and we have found two areas of concern. First, the at-risk groups are not just adolescents aged 16 to 19 but include those aged 20 to 25. In the latter group, there has been a steep increase in STIs. Secondly, we have found that alcohol misuse is the main cause of unprotected sex, leading to unplanned pregnancy and sexually transmitted disease among 16 to 19 year-olds in Birkenhead.

Other noble Lords have described the evidence of rising infection with gonorrhoea, chlamydia and HIV among teenagers in Britain. In the north-west, the rising infection rate is probably due to the availability of testing in the community, as well as in hospitals. It demonstrates the urgent need for a programme of public health focused on the needs of adolescents. Part of that increase is probably due to better detection. Young men need as much information and support as young women to keep healthy and to reduce the rate of teenage pregnancy and sexually transmitted infections.

We have little evidence on Merseyside of obesity in our teenagers, probably because we do not have a research programme. However, we know from studies of 1999 and 2000 that younger children, particularly those from four to 10, have shown evidence of increased rates of obesity.

It is clear that a programme of adolescent health would have to focus on the dangers of alcohol and binge drinking, unprotected sex, sexually transmitted infections, smoking, the abuse of drugs and healthy eating, as well as exercise and mental health—as my noble friend Lord Patel mentioned—areas identified in the BMA report.

When the Minister replies, will she indicate whether adolescent health will be part of the national service framework for children, particularly in the soon to be published documents?

8.51 p.m.

Baroness Masham of Ilton

My Lords, I thank the noble Baroness, Lady Massey of Darwen, for introducing this short but important debate. I congratulate the BMA on its report, which concerns some of the issues that several of us in your Lordships' House have been worrying about for some time. The noble Lord, Lord Warner, who was not able to be here today, knows this only too well, since as a Minister he has had to try to answer our questions.

The report says that current provision for sexual health services in the UK is woefully inadequate and services targeting the needs of adolescents are almost non-existent. Last Thursday I sat next to a professor of occupational therapy from Australia at the conference dinner of occupational therapy. When I told her that waiting times in Leeds and some other places at GUM clinics could be as long as six weeks if not longer she was horrified. She told me that in Australia it would be more like six hours, if the patient was not seen immediately.

The BMA report recommends immediate treatment of STIs, which can help to identify and treat sexual partners, avoid complications and prevent potential onward transmission. Offering sexual health promotion counselling to individuals newly diagnosed with an STI is also important because of the likelihood of reinfection.

HIV is on the increase. As there is so little publicity about it, the public are unaware of the situation. In England the latest figures indicate an increase of 78 per cent in cases of gonorrhoea since 1997; chlamydia infection has increased by 73 per cent; and syphilis by 374 per cent. The report says that one of the reasons for the current high prevalence of STIs is that most, such as chlamydia and gonorrhoea, may go undiagnosed because the infection is asymptomatic and screening is not widely available.

One piece of good news I heard today is that next year some pharmacists will be carrying out screening and testing for chlamydia, which has become an enormous problem for adolescent girls. Increased use of alcohol, drugs and marijuana at a younger age is related to subsequent risk assessment in sexual activity. Many adolescents can be difficult and will not listen to the advice of doctors, parents and teachers. They prefer to challenge the system. This is so dangerous.

Some months ago, I asked the Government whether STIs should be encompassed in a national service framework. Having read the report, I ask the same question again. Should that difficult and dangerous public health matter not be treated as a priority? I ask the Minister how many people a sexually active adolescent boy could infect if he had gonorrhoea and was not treated for six weeks. So often in healthcare provision, the adolescent falls between children's and adults' services. That vulnerable age-group needs special understanding and provision.

Eating disorders of all sorts can involve deep psychological problems. Obesity can cause all sorts of complex disorders such as diabetes and heart disease, but anorexia can cause death by starvation. I hope that the report will really make the Government sit up and listen, and I hope that PCTs will also take heed of it and realise what is going on all around them. We need a positive response from the Government. We also need some dynamic publicity campaigns aimed at young people, to help to prevent the increasing dilemma of bad habits that endanger the health of our nation.

What concerns me a great deal is the increase of underage drinking. Both boys and girls tend often to drink a mixture of alcohol until they are sick. By the time they reach maturity, they can become ill and liver disease can develop. There has been some skilful advertising by the drinks industry that attracts young people. There are not enough youth clubs with dedicated youth leaders. When there are, they are often vandalised. Computers and the Internet seem to dominate the lives of many adolescents. They become addicted and sit glued to the screen, and do not exercise in a healthy lifestyle. That encourages obesity and a static lifestyle.

Having been a member of a board of visitors of a young offender institution for years, I saw the increase of the problems of drug and alcohol abuse, yet the young people would tell me that leisure centres were too expensive. Can we ever win? I hope that the report will help to overcome that growing conundrum.

8.58 p.m.

Lord Clement-Jones

My Lords, despite the short notice of the debate and the altered timings, I am sure that all noble Lords agree that the debate has been extremely interesting and informative. We have had some very authoritative contributions. I congratulate the noble Baroness, Lady Massey, on seizing the opportunity to have the debate, which is on an extremely important subject.

If we take the combination of the BMA report, Adolescent Health, which makes extremely interesting reading, and the recent World Health Organisation survey on health behaviour in school-aged children, the outlook is rather depressing for the health of Britain's young people. British children are among the unhealthiest and unhappiest in the world, it seems. Sadly, one in five 13 to 16 year-olds can now be classified as obese. According to the WHO survey, adolescents in this country have more underage sex than those in almost any other country surveyed. Even more distressing—the noble Baroness pointed it out, among other matters—the BMA found that 60 per cent of 16 to 24 year-olds admit that they do not use condoms.

The noble Lord, Lord Chan, gave a catalogue of all the issues that surround adolescent health in this country. In its report, the BMA calls the downward trend in adolescent health a, potential public health time bomb". As we have heard tonight, that is, if anything, an understatement. If the health problems that young people are seeing now, including obesity, drug and alcohol abuse and sexually transmitted infections, are not addressed, young people will destroy their chances for good health later in life.

It is clear that the Department of Health needs to prioritise adolescent health by following the BMA's recommendation of rolling out healthcare services aimed specifically at teenagers. As many noble Lords have pointed out, young people are at risk of falling between the cracks in healthcare and have specific needs; while young children's needs are treated by paediatricians, the needs of adolescents are often not addressed in the current structure of services. If the BMA report has shown one thing, it is that adolescents have many varied health needs and addressing them now, so that they do not turn into lifelong health problems, may require the expansion of services specifically geared towards this age group.

One of the most disturbing findings of the Adolescent Health report is that rates of STIs are exploding among young people—not only adolescents, but younger children and young adults as well. Up to 10 per cent of women between the ages of 16 and 19 in this country may be infected with chlamydia, a disease that, if left untreated, can lead to pelvic inflammatory disease and infertility, as the noble Lord, Lord Turnberg, pointed out. Because the disease can be non-symptomatic in women, many of the young people transmitting the disease may not even know that they are infected.

The best methods for tackling adolescent health problems will need to draw both on health services and education resources. Many of the problems experienced by teenagers, from obesity to binge drinking and drug abuse, are having negative impacts on their mental health as well. The mental health aspect is so important. Incorporating programmes that address obesity at school level, from encouraging activity and sport—raised by my noble friend Lord Addington—to providing healthy school lunches can help children and adolescents establish healthy eating habits from the start. There are many successful models of those school-based interventions. As we read in the Health Development Agency's report last year, there are a number of successful models that we can use and we need to ensure that our health and education initiatives are joined up.

The school curriculum needs to include education on healthy food preparation and diet and avoid sending conflicting messages—whether by government or otherwise—by backing what is said and what is done. Currently school meals cost less than prison meals. We must have better nutritional standards in our schools. Physical activity, whether in the form of sport or simply walking to school, needs to become the norm, rather than the exception. I was dismayed to see a report that the Government had decided not to introduce a strict code for vending machines, but were to leave it entirely up to schools to decide whether to have them. That is not a satisfactory situation in our schools.

Likewise, a strong and comprehensive approach to sexual health is also necessary. Britain has the second highest rate of teenage pregnancy in the developed world. Not only chlamydia rates, but the prevalence of syphilis and gonorrhoea has risen sharply in the past five years. It is unreasonable to expect that young teenagers with sexual health issues will be taking time off school and approaching their GPs on their own to discuss sexual health and request screening for STIs. Those types of services need to be made directly accessible to young people and adolescents need to be aware of the services that already exist. Where adult sexual health services are not meeting the needs of adolescents, the NHS should look into how it could implement services designed with that target population in mind.

A well rounded approach that joins up education and health services would improve access to contraceptive services, improve and widen compulsory sex education and prioritise the national chlamydia screening programme, which many of your Lordships are impatient to see rolled out well before 2008. Approaching these issues from a preventive and educational standpoint will not only bring about the best benefits in terms of stopping the adolescent health time bomb, but will also reduce the burden that is bound to fall on the NHS in five or 10 years' time if young people's health is not improved as soon as possible.

Even more critically, we need to ask ourselves how the state of adolescent health reached this crisis. It is becoming more and more apparent that not enough is being done for children in terms of health education and disease prevention, as the noble Baroness, Lady Massey, pointed out in introducing the debate. The problems of childhood obesity and ill health do not disappear when children become teenagers; indeed, those diseases may be compounded by mental issues, such as depression, low self-esteem and poor self-image. If adolescent health is heading towards an explosion that will test the capacity of health services, it is because the health of children has not been a priority to date in the NHS or in schools. I hope that the Minister will address that problem as well as the services for adolescents.

9.5 p.m.

Lord McColl of Dulwich

My Lords, I, too, thank the noble Baroness, Lady Massey, for introducing this important debate. As the day wore on, I tore up page after page of my speech. When I found out about half an hour ago that I would have more time in which to speak, I could not find the pieces that I had torn up, but perhaps that is just as well.

As many noble Lords have already mentioned, obesity is, indeed, a very complex problem with many different factors involved. But one thing stands out with absolute certainty, and that is that we are what we eat and drink and, if we reduce our intake sufficiently, we will certainly lose weight.

Taking enough exercise is an important part of the obesity equation, as the noble Lord, Lord Addington, mentioned, but regular exercise is to be encouraged more for the benefit of the cardiovascular system and the general morale of the person. In fact, it is perfectly possible to reduce weight by reducing the amount that we eat without necessarily increasing the amount of exercise. I want to make it clear that a sensible and gradual reduction in food intake is quite different from the serious eating disorders, which can be very dangerous indeed, as the noble Baroness, Lady Massey, has already mentioned.

We need to encourage people to enjoy a sensible diet, always including a variety of starchy and fibre-rich foods with five portions of fruit and vegetables a day. That will satisfy our hunger in a way that junk food cannot. Let us take the example of a Big Mac and a large milkshake. That amounts to 1,500 calories, which can be burnt off with exercise but only by walking at a fast rate for four hours, which is hardly feasible for most of us.

The other problem is that, when an obese person reduces the amount that he eats and drinks, he loses weight but his resting metabolic rate also decreases and so he expends less energy. Therefore, someone who was previously obese but manages to get down to a normal weight tends to need fewer calories to maintain that weight than someone who has never been obese. That fact makes it difficult for him to maintain that weight loss by diet alone. Here, exercise is of great help.

When we are talking about obesity, it is important to decide exactly what we are talking about, and the best measure is the body mass index—the BMI. That is the weight in kilograms divided by the square of the height in metres. Therefore, an 11-stone man is 70 kilograms, that is divided by the square of his height, which we may suppose is six feet, and would equal a body mass index of 21. Healthy people should have a BMI of between 20 and 25, so that is all right. Those with a BMI in the range of 25 to 30 are overweight; those with a BMI above 30 are said to be obese; and those with a BMI over 40 are morbidly obese. For example, someone who is six feet tall and weighs 16 stones is obese, and someone who weighs 21 stones and is six feet tall is morbidly obese.

It is well worth avoiding obesity because it can be lethal. The risks, which have been mentioned, are diabetes, high blood pressure, gallstones, heart disease, osteoarthritis and many kinds of cancer.

It is all very well talking about the need to reduce obesity and the health services that these people need, but the Daily Telegraph today reported that health service obesity centres already have unofficial waiting lists of up to five years and are now closing their lists to new patients due to lack of money. So, clearly support for obese people is sadly lacking in some areas.

As has been mentioned, it is not for the nanny state to be telling people what to eat and how to order their private lives, but I think that government have a duty to send out a clear message. The Secretary of State for Health, John Reid, confused the issue by criticising the middle classes for imposing their anti-smoking agenda on the poor, but he should have known that support for a smoking ban crosses class boundaries. His message to the poor, "Let them smoke cigarettes", is rather reminiscent of Marie Antoinette's, "Let them eat cake" and equally as helpful. A MORI poll conducted for Action on Smoking and Health showed that the majority of the poorest classes and the majority of the wealthiest classes supported a ban on smoking in the workplace.

As to sexual health, I was especially pleased that the noble Baroness, Lady Gould of Potternewton, mentioned abstinence. The late Baroness Young, who was so respected throughout this House and throughout the country, suggested once at Question Time that the Government might consider pointing out that one way to enhance sexual health was to give a complete picture and also recommend abstinence as well as other precautions. The Minister of Health at the time replied that abstinence does not work. If he really believed that, as someone said at the time, perhaps he needed a tutorial on the facts of life. If, on the other hand, he meant that it had already been tried by some governments and failed, it would be interesting to know which governments he was referring to.

I should declare an interest in that I am involved with a hospice caring for people dying of AIDS in Uganda. There I saw at first hand President Museveni and his campaign of Abstinence, Be Faithful in Marriage and Condoms covering the whole scene. Thai has worked extraordinarily well and in terms of AIDS has brought down the incidence from 31 per cent to 7 per cent in pregnant women. That is very reliable data.

On another occasion when the same suggestion of abstinence was made, another Minister of Health in this House but not the present one—she would never say anything like this—said that it was only the elderly who recommended abstinence. Again, that is not true. It is the young in Uganda who have adopted this successful policy. Many young people in the western world are doing the same. Should government policy really be dictated by the personal preference of Ministers?

The Government have an obligation to publish all the facts about obesity and sexual health and an obligation to avoid too much political correctness.

9.14 p.m.

Baroness Andrews

My Lords, I join with other noble Lords in congratulating the noble Baroness, Lady Massey, on her sheer optimism in managing to secure the debate. This has been a good debate. I always listen with great care to doctors who speak in this House and we seem to have a high proportion of them tonight. We have ranged far and wide over the BMA report in very interesting ways, from the examples on Merseyside given by the noble Lord, Lord Chan, to the calculation of the BMI, the mystery of which was finally unravelled by the noble Lord, Lord McColl, for which I am grateful.

We are very grateful indeed to the BMA for this excellent report. It is coherent, wide in scope, very sharp in its focus and brings together a completely integrated account of what it is that young adolescents face and the issues that the policy should address. It is unique in addressing adolescents.

This evening I shall try to answer as many specific questions as possible, but I want to address the scenes the BMA put and I hope to illustrate how the Government share those basic priorities and how we are trying to address them. What is interesting about the debate is its timeliness. Many noble Lords have made powerful references to the very wide range of work in progress—the choosing health consultation due to finish soon and which will anticipate the White Paper on public health; the Food Standards Agency's work on food choices and obesity across the whole range; and the national service framework for children. These are all in progress, will come this year and will address many of the issues that we have spoken of this evening in very powerful ways. We look forward very much to that.

In this ferment of activity we have to keep our eye on adolescents because there is absolutely no doubt that they are at risk in different ways, such as when they are ignorant; when, as often, their aspirations for their own futures are very low; when their families are not supportive and when peer pressure is irresistible; and when they cannot get the services they need and fall through the gaps and cannot get the support. They do not know who or how to ask for the help they need.

At the same time, as noble Lords have pointed out, they are growing in independence and in autonomy; they are faced with potential for experiment, more likely to be influenced by their peer group and they are less susceptible to conventional messages. Many are not reached through school messages. I take the point made by the noble Lord, Lord Clement-Jones, about the central importance of schools in all this. We have to look outside the school and also at the context in which they are living their lives.

For these young people risks come not singly but in multiples. That is precisely the nature of the complication we seek to address. The BMA, with which we very much see ourselves as partners, has set out in the report a whole series of scenes of broad general points in relation to adolescent health: the need for early intervention and prevention; the need to target the most vulnerable; the need for coherent and integrated services; the need for consistent and intelligent messages; and, as many noble Lords have pointed out, the need for working on the transitional points, so that they do not fall in the gap between children and adult services. I would say that we also need to put that into the context of reducing inequalities.

Perhaps I may start with prevention and early intervention. The noble Baroness, Lady Gould, made a particular point of that. The point is that, as my noble friend Lady Massey said, if we are going to effect lifestyle changes—and we know how difficult it is to get adolescents to listen, let alone change—we have to start as early as possible. That is self-evident. It was interesting to hear the noble Lord, Lord Chan, say that some of the evidence of Sure Start is now showing how effectively it is working.

Sure Start is a flagship policy, but we begin with the reform of welfare foods, which this time last year we were debating in this House as part of the Bill dealing with the health service, so that mothers can choose not simply milk but from a wide range of goods.

I turn to what we are doing with schools. The food in schools programme may look modest, but it is a radical attempt to get to the heart of what children are choosing in school. That is where we are trying to enable them to change their habits of drinking fizzy drinks and to drink water from vending machines, have healthier tuck shops and more breakfast clubs so that they start the day in a healthier way.

Alongside that we are raising their programme of activity. I cannot give the noble Lord, Lord Addington, the information he sought, although he gave me prior warning. He also warned me that I would not be able to answer it. He was quite right. So I have to resort to saying that we are spending £581 million on refurbishing sports facilities. Irrespective of the relationship between weight loss and activity, I am sure that the noble Lord, Lord McColl, would agree that activity, as he said, is a very good thing. One of the problems that we have in the context of obesity is getting young women to take part in sport. It is a big challenge to wean the sports culture off team sports onto the sorts of activities that young women will choose, be that dance or aerobics. We must be much more intelligent about that.

The noble Baroness, Lady Gould, addressed the issue of schools directly in her criticism of the failures of past programmes of sexual health education. I have some sympathy with what she was saying. We must look at better ways of getting messages across. The business about language is essential. I shall come on to it a little later. In order to deliver messages about safer sex, we must be where those young people are, for example, using radio adverts and website information about STIs that tie in with the ever-popular Euro 2004 tournament. I thought that this might be a football-free zone this evening, but I am afraid that it is not. That is a good example of the way in which we can begin to target our messages.

Another thing that was positive in what the noble Baroness said is that we are developing a much better professional development programme, both for teachers and nurses. We are developing new certification programmes to help them to develop sex and relationships education and contribute to school programmes in different ways. That is an important step forward, as is the new Ofsted inspection system, which will really begin to drive that improvement. The noble Lord, Lord Turnberg, made some interesting suggestions about the importance of informal peer groups and what they can achieve in schools. He is right, and we have seen some positive outcomes from initiatives such as anti-bullying programmes, which are aimed at and delivered by adolescents.

The noble Lord, Lord Patel, addressed the question of mental health. Just in this one instance, I hope that I may use an illustration to answer the points that he raised. The early intervention teams, which are now being developed by the NSF, and which will pick up on earlier symptoms of psychosis will, with the follow-through with the young people and their parents, be an important step forward. We are putting child and adolescent mental health services on the map for the first time. We have a long way to go, but this is an important start. The NSF will include mental health standards and objectives.

The second thing that I want to say in relation to the BMA report is that we are targeting vulnerable groups. Complaints have been raised by noble Lords about the sexual health services. Yes, we have a long way to go, but we are trying. In relation to GUM services, for example, we are spending £41 million on refurbishment of centres. In reply to the noble Baroness, Lady Masham, we are trying to develop a 40-hour waiting time indicator, so that patients do not have to wait those very long times. Through the teenage pregnancy strategy, we are looking at a significant improvement. There has been a 10 per cent drop in teenage pregnancy since 1998. Because of the indicators that show that young women from social class 5 are 10 times more likely to become teenage mothers than those from social class 1, in the teenage pregnancy strategy we are concentrating our resources and initiatives on those areas where we can achieve the greatest reduction; those high rate areas. That is an extremely sensible thing to do.

The third area in which the BMA concentrated its argument was that services must be fully integrated and multi-professional. For the first time, we are trying to bring together, across these broad sections of policies, proper strategies that are evidence-based but have a long-term outcome. For the first time, and uniquely in Europe, we have a sexual health strategy. Indeed, if we are going to achieve the difference that we want, it will not simply be down to the sexual health strategy. The best contraception would be high achievement and high aspiration in schools. So we must be conscious of the fact that all these strategies lock together.

Noble Lords spent a great deal of time this evening talking about the explosion in sexually transmitted diseases. I do not want to reiterate anything that they have said, except to say to my noble friend that we are taking the epidemic of chlamydia extremely seriously. It is preventable and it is treatable. The chlamydia screening programme is focused on those aged under 25. We are implementing a national screening programme within the standardised framework which includes education, testing, diagnosis and treatment. Phase two was announced in January this year and a quarter of PCTs are now covered. By the end of the year, in phase three, a third of all PCTs will be covered.

Noble Lords may say that this is slow progress—there are many who wish we could go faster—but we are still on target to reach a national roll-out by 2008–09, which is earlier than we thought. We will keep up the pressure in this area.

Let me say another word about integration and give other examples of what we are aiming for in integrated policies. In relation to obesity, we are awaiting the Food Standards Agency review on food promotion to children which will address many of the issues across a wide front. We are already working with industry to reduce salt levels and so on.

As to the right messages, the vocabulary must not be one of blame or nagging; that would not work. Many noble Lords, including the noble Lord, Lord Addington, and my noble friend Lady Gould, referred to a failure to hear and a failure to listen. How can we reach these young people? All I can say is that we are trying very hard through programmes such as the teenage pregnancy national marketing campaign, the sex lottery campaign and the sex wise campaigns. We are using all the new technology and all the new ways of reaching young people that we can think of. We shall go on doing so. Eventually we will be judged by the success of this long-running campaign. We can combine it within the context of the other, more general, attempts that we are making across policies.

My noble friend Lady Massey asked me only one question, which I must try to answer. She referred to the research into adolescent health and I should like to say a few words about that. First, the teenage pregnancy research programme, which is now in progress, has five elements of research built into it. Secondly, the White Paper on choosing health may itself throw up some very interesting lines of research which we would want to follow up. Thirdly, the National Service Framework for Children is looking at underpinning evidence across a very wide range of policies. I agree that competent and trained professionals are the key to practically everything.

I am conscious that I am two minutes over time and that I have not answered some of the specific questions that have been raised. I should say in conclusion that it is all coming together, not only in the National Service Framework for Children—which will have a very heavy emphasis on other lessons and provide standards to aim for—but in the choosing health consultation, where we are looking very seriously at an agenda which is being driven by what people say they want and can manage. In practical terms, we already have bodies such as the children's trusts which are integrating services.

I am grateful for the debate, which was absolutely excellent. The key to much of what we want to achieve can be obtained only in partnership with young people themselves and by listening to what they say. I hope very much that we will get cleverer at that. My noble friend Lady Massey said that it must be easier to choose to live a healthier life. I entirely agree. That, of course, is our aim.

House adjourned at half-past nine o'clock.