The impact of body image on mental and physical health: government response to the House of Commons Health and Social Care Committee’s second report of session 2022 to 2023

Question 1

Introduction

Accepted Answer

This is the government’s formal response to the recommendations made by the Health and Social Care Committee in its report, The impact of body image on mental and physical health.

The government welcomes this report and is grateful to everyone who contributed their time and expertise to the inquiry. We especially value the personal experience testimony of witnesses.

We recognise that there is growing pressure on people to achieve an idealised body image, and that dissatisfaction with body image can have a significant impact on people’s mental and physical health throughout their lives.

The committee examined evidence relating to people’s perception of their body image, and their physical and mental health. The committee’s report set out its conclusions and recommendations in the following 6 parts:

the executive summary reviews the issues and evidence raised during the inquiry, and sets out how this informed the committee’s recommendations
chapter 1 provides the background on what drives poor body image, the impact that this has on individuals across their lives and the need for further research in this area
chapter 2 discusses the impact of body image on people’s mental and physical health, and covers body dysmorphic disorder (BDD), muscle dysmorphia, eating disorders and the negative links between body image, social media and advertising
chapter 3 considers body image and people’s experience of healthcare services, including access to healthcare services
chapter 4 focuses on the balance of tackling obesity and reducing weight stigma
chapter 5 discusses the rise and impact of cosmetic procedures, and the introduction of a licensing scheme for non-surgical cosmetic procedures

The report makes 21 recommendations. The structure of this command paper directly corresponds to these recommendations.

Question 2

Summary of government response to the recommendations

Accepted Answer

We strongly agree with the committee that there is a need for cross-government work to address the issues raised in the inquiry. The government remains committed to working together to address the growing problem around body dissatisfaction, and the impact this is having on people’s mental and physical health. We will consider what further action is required to address the issues raised by the committee.

The government has committed a significant amount of money to mental health research. The Department of Health and Social Care (DHSC) commissions research through the National Institute for Health and Care Research (NIHR). In 2021 to 2022, NIHR spent approximately £120 million on mental health research, which reflects a significant year-on-year increase in investment.

The government agrees with the committee that the diagnosis and treatment of BDD for adults, children and young people is a priority. Mental health professionals – including mental health nurses, psychiatrists, allied health professionals and psychological professionals – are skilled through their core training in the identification of BDD.

The government remains committed to helping individuals and families access resources to support them to tackle body image issues.

NHS talking therapies services (formerly known as improving access to psychological therapies (IAPT) services) offer evidence-based psychological therapy in the form of cognitive behavioural therapy (CBT) for BDD in adults. The government is committed to sustaining and extending access to these services so that more people can benefit. Family hubs:

help families to access and connect to a range of support, including mental health and emotional wellbeing support
connect parents and young people to advice on nutrition and weight management where appropriate

We welcome the committee’s assessment of the positive progress we are making on the delivery of mental health support teams (MHSTs) and the introduction of education mental health practitioners (EMHPs) within these. We have provided an update on MHSTs in line with the committee’s request.

We ask the committee to note that we are developing a major conditions strategy with the aim of publishing an interim report in the summer. The strategy will include prevention through to treatment for mental ill health, and we will continue to work closely with stakeholders in the coming weeks to identify actions that will have the most impact. As we expect eating disorders will be considered as part of this work, the government does not intend to publish a separate national eating disorder strategy.

The government agrees with the committee that image and performance-enhancing drugs (IPEDs) are a significant public health issue. We will continue to work with UK Anti-Doping (UKAD) – an arm’s-length body of the Department for Digital, Culture, Media and Sport (DCMS) – and other stakeholders to respond to the growing use of anabolic steroids in England.

We acknowledge the links between digitally altered body images and mental health. Through its work on the Online Advertising Programme (OAP), DCMS is considering how the government should approach advertisements that contribute to body image concerns, such as adverts that portray or present body types, cosmetic interventions, health products or medicines.

The government agrees there is a need to:

promote good screen habits for children and young people
make sure that screen time does not prevent them from engaging in activities vital for their health, such as exercise, socialising with family and friends, and sleep

Evidence suggests that further research is needed before forming a government strategy on children’s screen time.

The government has worked with Health Education England (HEE), the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC). All organisations are committed to ensuring that healthcare professionals have the necessary resources and training to discuss and address body image issues.

The government has no current plans to introduce nationally required annual holistic health and wellbeing assessments. We published an updated national health visiting and school nurse delivery model in 2021, providing guidance on how services can be commissioned and provided locally. We will continue to support commissioners in integrated care boards (ICBs) and local government with necessary resources.

The government is committed to supporting people to eat a healthy balanced diet and achieve a healthy body weight. We continue to do this:

by working with industry to ensure it is easier for people to make healthier choices
through a series of targeted policies that focus on those who are most vulnerable or at risk of dietary-related ill health

The government is committed to supporting consumers to make safe and informed choices about any cosmetic procedure they may choose to undergo. All cosmetic procedures have some risks. They can lead to serious complications if they’re not performed correctly and can affect an individual’s mental health if the results are not as expected.

The government is taking forward work to introduce a licensing scheme for non-surgical cosmetic procedures in England, but the scale of the work required to inform the regulations and establish the scheme means that we will not be able to meet the timeline recommended by the committee. DHSC will agree the procedures in scope of the licensing scheme and will communicate a plan for delivery by July 2023.

Question 3

Executive summary

Accepted Answer

Recommendation 1

As stated in paragraph 14:

We urge the government to immediately initiate a comprehensive cross-government strategy that brings together, at the very least, DHSC, DCMS and Department for Education (DfE) to tackle the current growing problem of body dissatisfaction, and its related health, educational and social consequences.

This strategy should include, but not be limited to, education on self-worth, body positivity, critical thinking and appraising images, as well as wider health advice such as spotting signs and symptoms of eating disorders, anxiety and depression, and body dysmorphia within educational, health and online or media settings.

We strongly agree with the committee that there is a need for cross-government work to address the issues raised in the inquiry and we are already taking forward action. There is not an immediate need for a standalone strategy, as multiple government departments – including DHSC, DCMS and DfE – are already working together to address many of the issues raised by the committee.

The government is committed to improving mental health and wellbeing outcomes. This is a key part of our commitment to ‘level up’, and address unequal outcomes and life chances across the country.

In April 2022, the government launched a 12-week public call for evidence on what can be done across government in the longer term to support mental health, wellbeing and suicide prevention. The responses we received have been processed, and will feed into the development of mental health and suicide prevention policies we include in the major conditions and suicide prevention strategies, which we will take forward this year.

The government has already set its ambition to make the UK the safest place in the world to be online through the Online Safety Bill, which will require services in scope to address illegal content and, where they are likely to be accessed by children, remove harmful content and activity such as content promoting eating disorders.

In July 2021, DCMS published the Online Media Literacy Strategy, which set out its ambition to:

improve the national media literacy landscape
support the empowerment of users with the skills and knowledge they need to make safe and informed choices online

The strategy includes a framework of 5 key principles that underpin strong media literacy, including being able to critically think about online content and building an understanding that the online environment is not always reflective of reality.

Body image is also covered in teacher training modules on respectful relationships, online relationships, online and media, mental wellbeing and physical health and fitness.

The Prevention Concordat for Better Mental Health programme focuses on promoting mental health and wellbeing in local authorities and integrated care systems, supporting the prevention of mental ill health.

The Better Health – Every Mind Matters campaign delivered by the Office for Health Improvement and Disparities (OHID) supports positive mental health and wellbeing by giving children aged 10 to 18 the skills to help them look after their mental health. This campaign includes:

NHS-endorsed video content via social media platforms
a website
relationships, sex and health education curriculum-linked classroom resources (for year 6 and key stage 3 and 4 pupils) addressing issues that affect young people’s mental wellbeing, including managing social media pressures and body image

The Healthy Child Programme provides an opportunity for health visitors and school nurses to identify at risk populations, and provide appropriate intervention and/or referral to appropriate services.

The government remains committed to working together to address the:

growing problem around body dissatisfaction
impact this is having on people’s mental and physical health

We will consider what further action is required to address the issues raised by the committee.

Question 4

What drives poor body image and who does it impact?

Accepted Answer

Recommendation 2

As stated in paragraph 31:

We recommend that DHSC, along with NIHR, commission and fund new research to understand the causal pathways that are leading to a rise in body image dissatisfaction across the population and the impact of social media on body image.

This is of particular importance in relation to groups that are known to be particularly affected by body image dissatisfaction: for example, adolescents, people with disabilities and LGBT people. However, it is also vital for groups in relation to which the understanding of body image dissatisfaction is less clear, such as those from BAME communities and older people.

DHSC commissions research through NIHR. In 2021 to 2022, NIHR spent approximately £120 million on mental health research, which reflects a significant year-on-year increase in investment. There is recent and ongoing research in relation to aspects of the areas raised in the recommendation. It is not usual practice for NIHR to ring-fence funding for particular topics or conditions – however, NIHR welcomes funding applications for research into any aspect of human health, including body image.

Qualitative research on young people’s experience of online eating disorder content has recently been published.

Further to this, NIHR is partnering with the Medical Research Council, the Economic and Social Research Council, the Arts and Humanities Research Council and the Medical Research Foundation to fund new collaborations to support eating disorders research. A key objective of this initiative is to encourage interdisciplinary collaboration by mobilising academia, industry, the charity sector, local authorities and service providers from associated areas to align their interest to eating disorders research. The specification welcomes proposals into “socio-cultural risk and protective factors, including body image and social media” and encourages applicants to consider under-represented groups living with eating disorders, including but not limited to:

middle-aged and older individuals
ethnic minorities
LGBT individuals
neurodiverse individuals

In August 2021, NIHR launched an ambitious Mental Health Research Initiative spanning NIHR-funded programmes and infrastructure, which included a £30 million investment to rebalance the scale of mental health research through:

broadening and understanding current mental health research capacity
supporting research collaborations across NIHR
funding high-quality mental health research

The initiative has a focus on regions and groups where mental health research is most needed, including children and young people, ethnic minorities, and people with pre-existing physical health conditions.

NIHR will continue to explore ways to address this recommendation for research that seeks to understand the causal pathways that are leading to a rise in body image dissatisfaction across the population and the impact of social media on body image.

Question 5

Impact of body image on health and lifestyle

Accepted Answer

Recommendation 3

As stated in paragraph 44:

We urge DHSC to ensure more is done to make the diagnosis and treatment of BDD a priority. From a diagnostic perspective, we recommend that HEE update the IAPT and EMHP curricula to make training in BDD compulsory for all mental health practitioners.

The government should ensure BDD is included in the PSHE (personal, social, health and economic) education curricula, within the section on body image, to promote early detection and early intervention within schools.

As well as improved diagnosis rates, suitable care for those living with BDD must be available. We recommend that BDD specialist practitioners are eventually embedded into the multidisciplinary teams in every new community model for adults severely affected by mental illness.

The government agrees with the committee that the diagnosis and treatment of BDD is a priority. This prioritisation is best achieved through the current training, referral routes and curriculum.

Mental health professionals, including mental health nurses, psychiatrists and psychological professionals, are skilled through their core training in the identification of BDD. Evidence-based treatment is delivered by specially trained staff.

NHS talking therapies (formerly IAPT) therapists are already trained in the identification and awareness of BDD, while high-intensity CBT therapists in NHS talking therapies are also trained in delivering the specific interventions. This service model is in line with the National Institute for Health and Care Excellence (NICE) guidance, which recommends high-intensity CBT as a treatment for BDD.

Staff in community mental health settings should also be able to identify and support this issue where it presents alongside serious mental illness, and the NHS England national mental health team is exploring how to improve the interface between NHS talking therapies and community mental health services.

The national obsessive-compulsive disorder (OCD) and BDD service is directly commissioned by NHS England, delivers highly specialised interventions in conjunction with local mental health services, and is available to people of all ages on the basis of need.

New community models are centred around an individual’s needs, and NHS England has not outlined a prescriptive service model or specific resourcing of sub-specialisms so integrated care systems can tailor their models to local population need. NHS England will continue to work closely with services and systems to understand how workforce development and training can support service users.

The EMHP curriculum is designed to equip trainees with the skills and competence to work with children and young people with common mental health problems, particularly mild to moderate symptoms of anxiety, depression and behavioural difficulties, through providing training to deliver low-intensity interventions in response. There is no explicit reference to BDD in the curriculum because these practitioners are not being trained to offer high-intensity CBT as recommended by NICE.

Any changes to the curriculum development must remain within the clinical scope of the low-intensity model, which BDD does not fit (based on NICE’s recommendation for high-intensity CBT as a treatment). EMHPs are encouraged throughout their training and in practice to:

recognise those presenting issues that may be of a complexity requiring additional support
help people access further advice and support for themselves, children and young people

This includes those related to body image.

EMPHs work in MHSTs, based within educational settings, alongside more senior therapists and supervisors who also provide clinical supervision. While it would not be clinically appropriate for EMHPs to diagnose and treat BDD, one of the key functions of MHSTs is to liaise with external specialist services to help children and young people to get the right support. This could include, for example, referral to a specialist eating disorder service or medical practitioner.

Body image is already covered in statutory relationships, sex and health education (RSHE), which is often taught as part of personal, social, health and economic (PSHE) education. Teacher training modules on these topics are free to download – however, schools have the freedom to ensure the curriculum meets the need of their pupils. This flexibility allows schools to respond to local public health and community issues, such as BDD, and adapt material and programmes to suit the needs of their pupils.

Recommendation 4

As stated in paragraph 45:

We call on the government to better equip future generations and their families with the skills and resources required to tackle body image issues. These skills and resources include critical thinking, particularly when it comes to appraising images, and self-worth.

We recommend that the government explores the use of family hubs as a route to educate parents and young people about body image, self-worth, and body positivity.

The government remains committed to helping improve families’ access to resources that support them to tackle body image issues. Family hubs are a way of joining up locally to:

improve access to services
reinforce the connections between families, professionals, services, and providers
prioritise strengthening the relationships that carry us all through life

They bring together services for children of all ages, with a great Start for Life offer at their core.

At the Autumn Budget and Spending Review 2021, the Chancellor announced a £301.75 million package to transform services for parents, carers, babies and children in half of local authorities across England. This includes funding for a network of family hubs.

We have published guidance for local authorities on the services we expect family hubs to offer, which includes supporting families to access mental health and emotional wellbeing support. This could include, for example, connecting parents and young people to online self-help materials such as the Every Mind Matters website, which addresses poor body image and low self-esteem.

We also expect hubs to connect parents and young people to advice on nutrition and weight management, where appropriate, and for staff in the hub to be able to talk about healthier weight in an informed and sensitive way.

Recommendation 5

As stated in paragraph 46:

We commend the government’s work to date to introduce EMHPs within school-based MHSTs across the country, as well as the commitment to have a mental health lead teacher in schools.

We recommend that the government review the training of these practitioners to ensure it includes spotting early signs of conditions related to body image issues. We ask the government to provide us with a further update on their progress in introducing these roles and to set out the timeframe for establishing them in every school in England.

The government welcomes the committee’s assessment of the positive progress we are making on the delivery of MHSTs and the introduction of EMHPs within these.

We have no plans to review the training of these practitioners as we believe current arrangements already provide opportunities to learn about mental health conditions related to body image issues. HEE works with partners on an ongoing basis to review and adapt the curriculum to allow EMHPs to provide psychological support and interventions for mild to moderate mental health problems. At this time, we believe the current curriculum to be fit for purpose within this level of intervention.

Upcoming registration for qualified EMHPs via the British Psychological Society and British Association for Behavioural and Cognitive Psychotherapies will require that individuals undertake additional training to support ongoing professional development. Training on BDD and other body image-related issues can be considered in line with opportunities available locally and local population needs.

DfE has committed to offering all state schools and colleges a grant to train a senior mental health lead by 2025. A senior mental health lead is a strategic role overseeing the implementation of a school or college’s overall approach to mental health and wellbeing. Learners choose courses to build on their existing knowledge and experience, which may focus on particular areas based on their self-assessment.

Over 10,000 schools and colleges – which includes more than 6 in 10 state-funded secondary schools – have taken up the offer so far, and DfE has confirmed £10 million in grants this financial year to offer training to two-thirds of schools and colleges by March 2023.

As of spring 2022, there are 287 MHSTs in place in around 4,700 schools and colleges across the country, offering support to children experiencing anxiety, depression and other common mental health issue. MHSTs now cover 26% of pupils – a year earlier than originally planned – and this will increase to 399 teams, covering around 36% of pupils, by April 2023 with over 500 planned to be up and running by 2024. The government will set out future plans in due course.

2,091 EMHP training places have been commissioned between 2019 and 2022. More than 1,608 EMHPs have been trained or are in training in universities across the country, alongside more than 600 senior staff.

The independent early evaluation of the MHST Trailblazer programme was published in July 2021, and indicated strong commitment to and support for MHSTs from health, education and wider local partners. We are using the evaluation findings and recommendations to inform EMHP training and to strengthen support for sites.

Recommendation 6

As stated in paragraph 54:

We recommend that the government develops a national eating disorder strategy that aims to understand the causal mechanisms that lead to the development of eating disorders, and earmarks adequate funding to bolster existing services, as well as to increase investment in research.

We further recommend that, alongside the quarterly publication of data on existing access and waiting time standards across every region, the government pledges and provides additional resources to address any increase in the need for treatment identified in order to eliminate regional inequalities in care.

As outlined in our response to recommendation 1 above, we are developing a major conditions strategy, which will include prevention through to treatment for mental ill health.

We will draw on the responses we received during last year’s 12-week public call for evidence on what can be done across government in the longer term to support mental health and wellbeing, as well as work closely with stakeholders in the coming weeks to identify actions that will have the most impact. As we expect eating disorders will be considered as part of this work, the government does not intend to publish a separate national eating disorder strategy.

The government accepts the research part of the recommendation. DHSC commissions research through NIHR. In 2021 to 2022, NIHR spent approximately £120 million on mental health research, which reflects a significant year-on-year increase in investment. It is not usual practice for NIHR to ring-fence funding for particular topics or conditions – however, NIHR welcomes funding applications for research into any aspect of human health, including body image.

Qualitative research on young people’s experience of online eating disorder content has recently been published. Further to this, NIHR is partnering with the Medical Research Council, the Economic and Social Research Council, the Arts and Humanities Research Council, and the Medical Research Foundation to fund new collaborations to support eating disorders research. A key objective of this initiative is to encourage interdisciplinary collaboration by mobilising academia, industry, the charity sector, local authorities and service providers from associated areas to align their interest to eating disorders research. The specification welcomes proposals into “socio-cultural risk and protective factors, including body image and social media” and encourages applicants to consider under-represented groups living with eating disorders, including but not limited to:

middle-aged and older individuals
ethnic minorities
LGBT individuals
neurodiverse individuals

In August 2021, NIHR launched an ambitious Mental Health Research Initiative spanning NIHR-funded programmes and infrastructure, which included a £30 million investment, to rebalance the scale of mental health research through:

broadening and understanding current mental health research capacity
supporting research collaborations across NIHR
funding high-quality mental health research

The initiative has a focus on regions and groups where mental health research is most needed, including children and young people, ethnic minorities and people with pre-existing physical health conditions. NIHR will continue to explore ways to address this recommendation for research that seeks to understand the causal pathways that are leading to a rise in body image dissatisfaction across the population and the impact of social media on body image.

Under the NHS Long Term Plan, the government has earmarked additional funding to bolster existing mental health services, including eating disorder services, until 2023 to 2024.

Since 2016, investment in children and young people’s community eating disorder services has risen every year, with an extra £54 million a year from 2022 to 2023. This extra funding will enhance the capacity of community eating disorder teams across the country. We will invest almost £1 billion extra in community mental health care for adults with severe mental illness by 2023 to 2024, which will give 370,000 adults and older adults with severe mental illnesses, including eating disorders, greater choice and control over their care and support them to live well in their communities.

In recognition of the rising demand created by coronavirus (COVID-19), we invested £58 million in 2021 to 2022 to support the expansion of adult community mental health services, including those for eating disorders. We invested £79 million extra to significantly expand children’s mental health services, including enabling at least 2,000 more children and young people to access eating disorder services.

NHS England continues to work with system leaders and regions, and to ask that areas prioritise service delivery and investment to meet the needs of these vulnerable young people and help ensure funding flows to these services as intended. To support this, NHS England is refreshing guidance on children and young people’s eating disorders, including to increase the focus on early identification and intervention. Updated guidance will highlight the importance of improved integration between dedicated community eating disorder services, wider children and young people’s mental health services, schools, colleges and primary care to:

improve awareness
provide expert advice
improve support for children and young people presenting with problems with eating
ensure swift access to specialist support as soon as an eating disorder is suspected

NHS England also invested a further £40 million in 2021 to 2022 to address the COVID-19 impact on children and young people’s mental health, including for eating disorders. As part of this, £10 million capital funding was used to provide extra beds at units that provide care for young people with the most complex needs, including eating disorders, as well as £1.5 million to ensure there are additional facilities for children under 13 years of age.

We are also taking steps to expand the number of practitioners who can deliver evidence-based psychological interventions that are intended to treat those with an eating disorder.

This includes expanding the number of individual trainees and qualified practitioners who are competent to deliver cognitive behavioural therapy for eating disorders (CBT-ED), as well as the Maudsley model of anorexia nervosa therapy in adults (MANTRA).

HEE also delivers specialist eating disorder training for avoidant restrictive food intake disorder (ARFID), through the Maudsley model, to professionals working in child and adolescent mental health services, and family therapy for anorexia nervosa and bulimia nervosa training for clinical staff working with young people.

Recommendation 7

As stated in paragraph 59:

We recommend that DHSC commissions a national review of the growing use of anabolic steroids in England as it relates to body image.

We further recommend that DHSC introduces a national awareness campaign around safe anabolic steroid use. This ought to be co-ordinated through existing steroid user support groups and targeted at areas of highest risk, such as gyms with a high proportion of body builders.

The government agrees with the committee that IPEDs are a significant public health issue. Recent research and campaigns have already addressed the actions highlighted in the recommendation.

In January 2020, UKAD, an arm’s-length body of DCMS, published a report on IPEDS highlighting the increased usage of these drugs among young males outside of sport for cosmetic purposes.

In November 2018, UKAD announced a partnership with ukactive to improve education and awareness around IPEDs in gyms and leisure facilities. The partnership is aimed at exploring:

attitudes around IPEDs among gym users
how best to support operators, coaches and personal trainers to help keep sport and exercise clean

This follows a recommendation made in the Tailored Review of UK Anti-Doping in 2018, which set out the opportunity for UKAD to:

influence the fitness sector
work with representative bodies to promote improved guidance and knowledge on the use of safe supplements

The issue of the growing use of anabolic steroids in England is a shared responsibility, and one upon which the government, UKAD and others will continue to work together.

Recommendation 8

As stated in paragraph 66:

We call on the government to work with advertisers to feature a wider variety of body aesthetics, and work with industry and the Advertising Standards Authority (ASA) to encourage advertisers and influencers not to doctor their images.

We believe the government should introduce legislation that ensures commercial images are labelled with a logo where any part of the body, including its proportions and skin tone, are digitally altered.

The government acknowledges the possible link between digitally altered body images and mental health, including the potential harms such a link may cause.

Through its work on the OAP, DCMS is considering how the government should approach advertisements that contribute to body image concerns, such as adverts that portray or present:

body types
cosmetic interventions
health products
medicines

The government recognises the work that ASA has already done in this area via standards setting, training and formal rulings, and looks forward to working alongside ASA to identify the appropriate course of action.

The consultation on the OAP closed on 8 June 2022, and DCMS is currently analysing consultation responses and developing policy. DCMS will be setting out more details on its intended actions in the government response to the OAP consultation, which will be published in due course.

Our priority will be to ensure that any intervention is evidence based, and makes a real and positive difference.

In addition to this, the government will work with both ASA and the Incorporated Society of British Advertisers regarding the organisation’s roles in encouraging advertisers and influencers against doctoring images. The extent of DCMS’s role in this work will be decided as the OAP develops.

The government believes that the range of body aesthetics featured in advertisements is ultimately a decision for advertisers and brands to make. However, the government recognises the committee’s view surrounding the role that greater representation of diverse body types could play in reducing negative body image and would welcome industry initiatives in this space.

Recommendation 9

As stated in paragraph 69:

We echo the call of our witness Professor Sandeep Ranote for the creation of a national public health strategy akin to the 1970s Green Cross Code. A ‘Screen Cross Code’ would be a nationwide public health campaign, which would use short effective messages to educate the public on best practice with screen use for children and young people, as well as the potential negative health impacts resulting from excessive screen use or exposure to content that may lead to body dissatisfaction.

This should include limits on daily screen use, promotion of social media sabbaticals, having digital sunrises/sunsets, as well as prompts to encourage discussion between parents and their children if there is content that could cause concern relating to body image and self-esteem.

We recommend that DHSC plays a leading role, in collaboration with DfE and DCMS, in this work, given its implications for young people’s health.

We welcome the committee’s attention on this matter. The government recognises that there is a need to promote good screen habits for children and make sure that screen time does not prevent children from engaging in activities vital for their health, such as exercise, socialising with family and friends, and sleep.

We are aware that current evidence shows that not all screen time is harmful for children’s health and that much more research is needed before developing national guidance or consistent limits on screen use.

DHSC will collaborate with DCMS and DfE to establish how best to gather robust evidence on this issue before deciding whether to progress with a nationwide public health campaign. Any future public health campaign would also be contingent on future funding settlements.

Existing measures in place

The government is already committed to ensuring that children are not negatively impacted from online content and activities.

DfE’s statutory guidance on relationships, sex and health education states that pupils should know about:

the benefits of rationing time spent online
the risks of excessive time spent on electronic devices
the impact of positive and negative content online on their own and others’ mental and physical wellbeing

DfE has also produced guidance, Teaching online safety in schools, which supports schools to understand how they can embed this across a number of curriculum areas.

As mentioned earlier in this report, in July 2021, DCMS published the Online Media Literacy Strategy, which sets out how the government is providing users with the key skills and knowledge they need to make safe and informed choices online. This includes:

supporting citizens to take action to manage their screen time and online wellbeing
calling on online platforms to take steps to support their users, including through their platform design choices

Question 6

Body image and experience of healthcare services

Accepted Answer

Recommendation 10

As stated in paragraph 77:

We urge HEE, GMC and NMC to collaborate with third-sector organisations that are currently educating people about and promoting awareness of body image issues, and, after a period of assessment, integrate the most effective existing training and resources into all training programmes within the medical, nursing and midwifery fields within the next 2 years.

We echo the Mental Health Foundation’s recommendation for any further training for professionals interacting with parents – that is, GPs, health visitors, dietitians and other frontline practitioners – to include information about how parents and carers can, from a very early age, positively influence their children’s feelings about their bodies through the behaviours and attitudes they express.

HEE, GMC and NMC welcome this recommendation, and all are committed to ensuring that healthcare professionals have the necessary resources and training to discuss and address body image issues.

Education and training

HEE

HEE agrees that collaboration will help to positively influence how parents and carers support children with healthy body image. However, HEE does not have governance responsibility for education of the whole workforce.

For example, HEE is not responsible for the certificate of completion of training, which confirms that doctors have completed an approved UK training programme and are eligible for entry onto the Specialist Register or GP Register regulated by the GMC. This includes postgraduate doctors in training (PgDiT), such as GP specialty trainees and doctors in training in hospital-based specialties, who may be involved in the care of patients with eating disorders and body image issues.

HEE also does not set the education standards for pre-registration nurses or midwives as this is the role of NMC. The approved education institutes are responsible for ensuring that curricula meet those standards.

Service provider organisations are responsible for ensuring their staff have the capability to deliver care, and provide mandatory and in-house training where applicable.

Where possible, HEE continues to influence the training and professional development of those delivering services through continued collaborative work with key strategic stakeholders, including an eating disorder credential, which is a training pathway offered to consultants who are on GMC’s Specialist Register to train in a specialist area that was not undertaken prior to the receipt of their specialist registration.

GMC

GMC sets the high-level outcomes for graduates of UK medical schools leading to entry on to the medical register, and approves the curricula for postgraduate training of doctors.

GMC quality-assures both aspects of medical training against its standards, but it does not set the content of medical curricula for undergraduate or postgraduate training. Educational leads and clinical experts at medical schools and colleges or faculties decide the content of curricula.

GMC does, however, describe the generic professional capabilities that should be included in all postgraduate curricula, and has prioritised capabilities and outcomes in themes relevant to eating disorders, such as nutrition, mental health and vulnerable groups.

GMC has also included eating disorders and related patient presentations – abnormal eating or exercising behaviour, weight loss, and weight gain – in the content map for the new Medical Licensing Assessment (MLA). The MLA content map:

sets out the areas that students could be tested on
provides a reference point for medical schools when developing final clinical and professional skills assessments

All students graduating from UK medical schools from the academic year 2024 to 2025 will need to pass the new assessment, which will also replace GMC’s current test for international medical graduates.

NMC

NMC’s education standards are high-level and outcome-focussed, enabling professionals to meet the holistic physical and mental health and care needs of all people, including those experiencing negative body image. This approach enables approved education institutions (AEIs), who write pre-registration nursing and midwifery curricula, to regularly update programmes considering new research and evidence when it arises.

It is, therefore, education institutions delivering nursing and midwifery programmes that are responsible for delivering on this recommendation, as it is AEIs who determine specific curricula on body image at individual universities.

The NMC Code sets out the need for all its professionals to prioritise people, and keep knowledge and skills up to date to ensure competence and improve outcomes. NMC’s new standards of proficiency for professionals place an emphasis on health and wellbeing, person-centred care and acting as an advocate for the vulnerable.

For example, NMC’s new post-registration standards of proficiency – including for health visitors and school nurses – have been updated to ensure these professionals:

are ideally placed to lead and influence public health services
are culturally competent
address health inequalities
make a difference to the health and the wellbeing of people of all ages, and across communities and populations

Recent and ongoing work

There are a number of evidence-based psychological interventions that are intended to identify and treat those with an eating disorder, and HEE is working to expand the number of practitioners who are able to deliver this and also the places where they provide this care.

To enable this, HEE is delivering and expanding training to support the current and new workforce to care for people with eating disorders, including increased capacity to deliver evidenced-based therapies such as CBT-ED and whole-team training to ensure that eating disorder teams can function effectively and safely. This includes:

HEE has commissioned the Royal College of Psychiatrists to develop an eating disorder credential that is currently being piloted. The aim is to improve quality of care and patient safety, and support the addressing of vacancy rates in eating disorder psychiatry.

HEE is also working with the leading UK eating disorder charity, Beat, who have produced training for nurses, doctors, and other health and care staff across the sector. This includes training on:

understanding and recognising the early signs of eating disorders
how to communicate with service users about their possible eating disorder
how to refer to a specialist community eating disorder service

GMC has also worked with Beat on the development of a new training package for medical students and foundation year 1 doctors in collaboration with the Royal College of Psychiatrists’ faculty of eating disorders. The training package was launched in summer 2021. GMC promoted the new training package to education leads at medical schools and foundation schools.

In 2020, GMC agreed with Foundation Programme and eLearning for Healthcare Leads that new bespoke e-learning resources would be developed to support foundation doctors as well as doctors in specialty training. This was funded by HEE.

GMC has commissioned the Academy of Medical Royal Colleges to work with colleges to create a suite of shared curricula content that specialties can tailor to their own needs. The aim of this is to ensure high standards in core clinical areas. As a priority, the first area being covered is eating disorders.

We will continue to work with GMC, NMC, HEE, the Medical Schools Council and others to share information and explore possible new actions.

Question 7

The balance of tackling obesity and reducing weight stigma

Accepted Answer

Recommendation 11

As stated in paragraph 86:

We propose that, in line with the introduction of integrated care systems that seek to tackle health inequalities and focus on prevention, DHSC ought to bolster the Healthy Child Programme, the programme for prevention and public health of children and young people aged 0 to 19 years old and their families.

We propose that the government introduce annual holistic health and wellbeing assessments for every child and young person, using the existing workforce of school nurses and health visitors, as well as those in associated roles such as community paediatrics and primary care.

These assessments should monitor a range of physical and mental health markers including, but not limited to, weight and mental wellbeing. They should provide an opportunity to explore the context in which the young person and their family live, and how these circumstances can relate to their health. They should aim to engage the wider family (if appropriate, depending on age) to ensure early detection of potential health risks, with signposting to appropriate services if required.

There are no current plans to introduce nationally required annual holistic health and wellbeing assessments.

An updated national health visiting and school nurse delivery model was published in 2021, providing guidance on how these services can be commissioned and provided locally. It provides greater emphasis on assessment of children, young people and family needs, and the skill mix to respond. This is to support local commissioning decisions and relevant partners in local authorities, the NHS, voluntary sector and partners.

There are no mandated reviews for school-aged children. However, there are opportunities to develop reviews based on evidence and clinical judgement. These are suggested at important development stages and transition points.

Partnership, integration, communication and multi-agency work remain key to improving outcomes. We will continue to support commissioners in ICBs and local government with resources, including a menu of evidence-based interventions for the Healthy Child Programme to address the needs of children and families.

Recommendation 12

As stated in paragraph 87:

We urge the government to implement population-level policies that ensure healthier choices and lifestyles are made a priority in tackling obesity rates, rather than schemes that focus solely on weight loss and can engender weight stigma and result in adverse health outcomes.

We were disappointed by the government’s delay in restricting multibuy deals for foods and drinks high in fat, salt or sugar – including ‘buy one get one free’. We urge the government to reconsider this decision and to implement this measure immediately.

Obesity is a complex public health challenge to which there is no single solution, and as such our policies include population-wide interventions as well as more specific targeted interventions for those most in need.

We have been careful to consider the views of mental health charities and experts as we developed our plans for implementing measures to improve diets and reduce obesity, and we will continue to listen going forward. This includes feedback from a wide range of experts in response to our public consultations on specific policy proposals.

We are working with the food industry to ensure it is easier for people to make healthier choices and increase progress on the reformulation of foods. Measures include new regulations on calorie labelling for out of home food sold in large businesses including restaurants, cafes and takeaways, which came into force on 6 April 2022, and restrictions on the promotion by location of products high in fat, salt or sugar, which came into force on 1 October 2022.

The locations restrictions, which mean that products high in fat, salt or sugar will no longer be promoted in key locations such as checkouts and aisle ends, are the single most impactful obesity policy at reducing children’s sugar and calorie consumption. These restrictions are expected to accrue health benefits of over £57 billion and provide NHS savings of over £4 billion over the next 25 years.

Through our reduction and reformulation programmes, we are encouraging the food industry to make everyday food and drink lower in sugar, salt and calories. We have seen some important successes, including the average sugar content of:

breakfast cereals and yoghurts decreasing by 14.9% and 13.5% respectively
drinks subject to the Soft Drinks Industry Levy decreasing by 46% between 2015 and 2020

Recommendation 13

As stated in paragraph 96:

We recommend that the government undertakes an urgent review of its current campaigns related to obesity and alters any language or media used that fail to mention that being underweight is as big a risk as being overweight.

We also recommend that training on weight stigma is integrated into undergraduate and trainee curricula in all medical, nursing and other allied professional programmes to address stigma early on. This requires professional bodies and HEE to update their curricula and training standards, coupled with training offered to all current clinical staff, on how best to discuss weight and health.

OHID uses a person-centred approach when writing about obesity and is guided by organisations such as Obesity UK’s Obesity Language Matters Guide and the principles of good practice for interactions between healthcare professionals and people living with obesity. OHID also researches and advises how best to talk to families about their weight in the most enabling and positive way.

OHID’s Better Health adult obesity campaign was developed with guidance from public health experts. OHID has also liaised with appropriate organisations, including a consultant psychiatrist, a charity working with people living with obesity and relevant physical activity organisations. In addition, OHID has worked with the charity Beat to ensure that feedback from those living with eating disorders is fed into the campaigning process.

Campaign materials are extensively researched to ensure that the campaign is not seen as judgemental or blaming and does not stigmatise people for how they live their lives. The people featured in the campaign are shown positively – making manageable changes to improve their health.

The main tool to which we guide those who are overweight or living with obesity is the NHS Weight Loss Plan app, which asks users to enter their height and weight as part of the set-up process and, if they are a healthy weight or are underweight, they receive a message explaining that this weight loss tool is not appropriate for them.

Better Health’s information on children’s weight now includes evidence-based tips to help parents talk about weight and healthy growth with their child, if they choose to, and the National Child Measurement Programme (NCMP) is trialling new approaches and resources to help parents and healthcare professionals talk about weight in a supportive way via an ‘extended brief intervention’ as part of the child and family weight management services grant.

The NCMP updates annual operational guidance for all delivery staff, including school nursing teams, to ensure measurements are conducted in a sensitive and non-stigmatising way. OHID has also developed guidance to support practitioners delivering the programme locally to engage in supportive conversations with parents about the NCMP and their child’s health.

Training on weight stigma

Training standards are the responsibility of independent statutory regulatory bodies across the healthcare sector such as GMC, NMC, and the Health and Care Professions Council.

It is expected that all relevant staff are able to:

demonstrate appropriate personal and professional values
practise in a compassionate, respectful way, maintaining the dignity and wellbeing of their patients, and communicating effectively with them

These requirements are set out in the standards of GMC and in the NMC Code.

In November 2021, OHID launched training for all primary care networks, healthcare practices and pharmacies on equipping their staff to become healthy weight coaches. The training material:

explains the importance of identifying how to avoid weight stigma by looking at attitudes, behaviour, communication and language
reflects on the concept of ‘best weight’, which promotes body acceptance
recognises that food choice and activity levels are an important aspect of a person’s social and cultural life

Recommendation 14

As stated in paragraph 97:

There needs to be further research to establish how best to tackle obesity while eliminating weight stigma and discrimination, and to establish the efficacy of weight-neutral interventions, and we recommend that NIHR put aside funding for this purpose.

NIHR has a large portfolio of research that seeks to understand how best to support people to achieve and maintain a healthy weight. This includes:

research on weight management interventions for individuals with unwanted weight
large-scale evaluations of population-level policies to support healthier eating such as the Soft Drinks Industry Levy
assessment of local policies such as the ban on advertising of food and drink high in fat, salt or sugar on the Transport for London network

NIHR welcomes funding applications for research into any aspect of human health, including tackling weight stigma and discrimination, and lifestyle interventions to support health. It is not usual practice to ring-fence funds for particular topics or conditions. Applications are subject to peer review and judged in open competition, with awards being made on the basis of:

the importance of the topic to patients, and health and care services
value for money
scientific quality

Question 8

Non-surgical cosmetic procedures

Accepted Answer

Recommendation 15

As stated in paragraph 109:

The risk of exploitation of vulnerable groups seeking non-surgical cosmetic procedures is too great and we recommend that, to prevent further exploitation, DHSC immediately draws up a clear timeframe for the consultation process.

We urge the government to make this a priority and to introduce the licensing regime for non-surgical cosmetic procedures by July 2023.

In April 2022, the Health and Care Act gave the Secretary of State for Health and Social Care the power to introduce a licensing regime for non-surgical cosmetic procedures in England. The purpose of the scheme would be to ensure that consumers who choose to undergo a cosmetic procedure can be confident that the treatment they receive is safe and of a high standard.

Officials have been considering how a future licensing scheme for non-surgical cosmetic procedures in England might be implemented. Key issues include:

the need for practitioners offering procedures within the scope of a licensing scheme to demonstrate that they have received the appropriate training, hold relevant qualifications and are operating from suitable premises
administration and enforcement by local authorities, and the imposition of penalties for those who fail to meet these standards
the scope and detail of a licensing scheme to be proportionate to the risk of harm that specific procedures or techniques are deemed to pose
the requirement for a licensing scheme to be expertly informed and involve extensive consultation with stakeholders and the public

The government is taking forward work to introduce a licensing scheme for non-surgical cosmetic procedures in England, but the scale of the work required to inform the regulations and establish the scheme means that we will not be able to meet the timeline recommended by the committee. DHSC will agree the procedures in scope of the licensing scheme and communicate a plan for delivery by July 2023.

Recommendation 16

As stated in paragraph 114:

We recommend that the new licensing regime for non-surgical cosmetic procedures includes a commitment to a 2-part consent process for anyone considering having a non-surgical cosmetic procedure, including, at a minimum, a full medical and mental health history, as well as a mandatory 48-hour cooling-off period between the consent process and undergoing the procedure.

We further believe that patients or clients who are considering any treatments should always be provided with information in an accessible format to ensure they are able to make an informed choice about their proposed treatment.

Practitioners carrying out non-surgical cosmetic treatments are not currently required to undertake a mandatory risk assessment of patients before offering a procedure.

The government is committed to supporting consumers to make safe and informed choices about any cosmetic procedure they may choose to undergo. All cosmetic procedures have some risks. They can lead to serious complications if they’re not performed correctly and can affect an individual’s mental health if the results are not as expected.

GMC has guidance for doctors offering cosmetic procedures. The key points in this guidance that are relevant to this recommendation specify that doctors:

must be familiar with GMC’s separate guidance on decision-making and consent
should have a clear discussion with their patients about the outcome, benefits and risks of cosmetic treatments
should give patients time to reflect so that they can make an informed decision
should take into account their patients’ vulnerabilities and psychological needs
should market their services responsibly
should not allow any financial or commercial interests in a particular intervention – or organisation providing cosmetic interventions – to adversely affect standards of good patient care

We encourage anyone considering a cosmetic procedure to take the time to find a reputable, insured and qualified practitioner, as well as reflect on the possible impact of the procedure on both their physical and mental health.

Choosing a practitioner subject to statutory regulation or on a voluntary register accredited by the Professional Standards Authority provides assurance that they hold the requisite knowledge, qualifications and insurance to safely perform the procedures they are offering.

Recommendation 17

As stated in paragraph 117:

There should be specific premises standards for all beauty salons and non-Care Quality Commission (CQC) registered premises providing non-surgical cosmetic procedures.

Local authority enforcement officers should be given extended powers to enforce compliance with a nationally agreed set of premises standards.

There are currently no specific premises standards for beauty salons and non-CQC-registered premises providing non-surgical cosmetic procedures.

We will consider whether specific premises standards are needed and what they should include. We also want to ensure that we do not duplicate inspection regimes. We will, therefore, continue to work with CQC to ensure that, if introduced, any new premises standards operate consistently with regulatory frameworks already in place.

We strongly encourage anyone considering a cosmetic procedure to take the time to find a practitioner who is operating from a premises that is compliant with hygiene standards and infection control measures.

Recommendation 18

As stated in paragraph 120:

We are convinced that there is a need for a minimum standard to be met in regard to the education and training of practitioners who perform non-surgical cosmetic procedures. It is essential to ensure patient safety, and thus should be a central pillar of a future licensing regime.

The Professional Standards Authority should be given the power to oversee a register of approved training providers. All training providers should have to meet an Office of Qualifications and Examinations Regulation (Ofqual) regulated standard.

The government agrees that those who offer non-surgical cosmetic procedures to the public should be suitably trained and qualified.

We recognise there is a need for nationally recognised standards covering the education, training and qualifications required for the administration of non-surgical cosmetic procedures.

The Joint Council of Cosmetic Practitioners (JCCP) has already developed a competency framework covering high-risk non-surgical cosmetic procedures and there are a limited number of bodies currently able to offer training courses on non-surgical cosmetic procedures. This includes universities, colleges and private training companies.

There are also a range of Ofqual-approved qualifications that are delivered by recognised Ofqual awarding bodies.

We will work with JCCP and other relevant stakeholders to consider whether further education and training requirements are necessary.

Recommendation 19

As stated in paragraph 123:

We recommend that DHSC reviews the licensing of dermal fillers to be prescription-only substances, in line with Botox, in order to provide more protection for people undertaking procedures involving dermal fillers.

The government recognises that there are significant physical and psychological risks that cosmetic fillers (commonly known as ‘dermal fillers’) present to members of the public.

Filler products can be used for medical treatment or for aesthetic purposes. In England, the Botulinum Toxin and Cosmetic Fillers (Children) Act 2021 prohibits the availability of ‘Botox’ and dermal fillers to under-18s for cosmetic purposes.

Currently, a dermal filler may be regulated either as a general product, a medicine or a medical device, depending on its composition and intended use. Fillers classified as general products are not subject to licensing or manufacturing controls, and do not need a prescription to be obtained.

The Medicines and Healthcare products Regulatory Agency (MHRA) is responsible for the regulation of medical devices, and intends to bring in more stringent rules for certain aesthetic and non-medical products, including dermal fillers, under the UK medical devices regulations.

There are no current plans for MHRA to make dermal fillers prescription only. Unlike Botox, dermal fillers cannot be covered by the existing prescription-only medicine framework because they are medical devices rather than medicinal products.

We strongly encourage anyone considering dermal fillers to take the time to find a reputable, insured and qualified practitioner.

Recommendation 20

As stated in paragraph 124:

We recommend that DHSC establishes a Non-Surgical Cosmetic Procedures Safety Taskforce that comprises each of the regulatory bodies that have input into the sector, including MHRA, the 9 statutory bodies, ASA, and stakeholders like JCCP, Save Face and other industry bodies.

This taskforce’s remit should be centred on patient safety and should include, but not be limited to, examining the issues of remote prescribing, appropriateness of premises, education and training standards, as well as accountability and governance. The existence of a taskforce should provide the opportunity for a more co-ordinated approach. The taskforce should also review the impact and operation of the future licensing regime when it is in place.

We also heard evidence about the difficulties in enforcing existing regulations of non-surgical cosmetic procedures as complaints relating to an aesthetic practice often span a number of different regulators. The new safety taskforce must ensure a co-ordinated approach to the enforcement of new and existing regulations in the industry, and the government must ensure sufficient resources are available to the relevant bodies.

The government is grateful to all the organisations and bodies involved in ensuring that the cosmetic industry is appropriately regulated, and for their ongoing positive engagement with this work.

Officials in DHSC already have effective working relationships with regulatory bodies, including all professional healthcare regulators, CQC, ASA and MHRA. We also work closely with key stakeholders in the industry, including JCCP, Save Face, the British Beauty Council and other industry bodies.

We will continue to work with relevant stakeholders to ensure consumers can make safe and informed choices about any cosmetic procedure they may choose to undergo.

Recommendation 21

As stated in paragraph 129:

We recommend that the new licensing regime should include the requirement to display a kitemark and a warning logo on any advertisement for treatments that fall within the regime’s scope.

The government wants to ensure that the public can trust any medicine or device used during a non-surgical cosmetic procedure. We also want to ensure that any practitioner or organisation offering non-surgical cosmetic procedures markets their services and products responsibly.

Kitemarks

The British Standards Institution (BSI) Kitemark is a quality mark owned and operated by BSI – a recognised symbol of quality and safety. There is no prescribed requirement for a BSI Kitemark on medical devices being placed on the UK market.

Any medical device placed on the UK market must meet product marking requirements, including relevant CE or UK Conformity Assessed (UKCA) marking requirements.

The government has recently outlined plans to strengthen medical devices regulation, including extending:

CE mark recognition as part of transitioning to a future regime
the scope of regulations to capture certain non-medical products with similar risk profiles to medical devices – this includes dermal fillers

Find out more in the government’s recent response to the consultation on the future regulation of medical devices in the UK.

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