Dr Rupy: Increasing fruit and vegetable consumption sounds so trivial, but I honestly believe that concerted efforts to increase this key measure of our diet quality would culminate in success. And by success, I mean successfully improving people's health, but also increasing the wealth of our communities and alleviating our nation's food supply insecurity. And to explore this concept further with me is Jonathan Pauling, CEO of Alexandra Rose, one of my favourite charities and one that Doctor's Kitchen supports. 10 years ago, Jonathan helped develop its new mission, which is to improve access to healthy and affordable food for all. And they built the Rose Vouchers for fruit and veg to pioneer the use of financial incentives to help families on low incomes avoid food insecurity, nutrition insecurity, which is a concept that we also explore in today's podcast, and food-related ill health. And from these small pilots in London supporting 45 families, this work has now spread across the UK, supporting three and a half thousand families every week. The scheme works by giving families literal cash in the form of Rose Vouchers that can be used at local food markets in exchange for fresh produce. It's increased fruit and vegetable consumption by a staggering amount, as we'll get into during this discussion, and I was genuinely shocked at some of the impressive numbers that Jonathan shared with me. Today we're going to explore the economic and health incentives for why this scheme should be adopted across every local authority and NHS commissioners to not only help the millions of people living in financial hardship in the UK, but also alleviate the burden on our health system. This is something, as you can tell, I'm very, very passionate about. I even wrote my master's dissertation on this very subject, exploring the use of digital apps to increase fruit and vegetable consumption, which is why I actually started the Doctor's Kitchen app in the first place. And if you're inspired by fruit and vegetables and you're looking at some fruit and vegetables in your kitchen or in your fridge, you're like, what do I do with this? How do I put this into a recipe? Do yourself a favour, go to the doctorskitchen.com on your phone, or if you've downloaded the Doctor's Kitchen app, you can use your Android device or your iOS device, go to the search bar and type in that fruit and vegetables. Type in tomatoes, type in kale, type in mushrooms, whatever you have in your fridge or on your kitchen worktop, and you will be staggered by the number of recipes that we have there. We have hundreds of recipes, all tailored to your unique health goals, your dietaries, your allergens, and recipes that genuinely your family or your partner will enjoy. Trust me, thousands of people have used it and we get feedback about this every single week. It's one of my proudest achievements and one that I hope to grow as much as possible to get people super excited about the flavour of fruit and vegetables, but also the health benefits of consuming this kind of way every single day. For now, enjoy my podcast with the wonderful Jonathan Pauling, CEO of Alexandra Rose. Jonathan, tell me about why we should care about fruit and vegetable consumption at all.
Jonathan: Well, I think it's one of the key things that is a sort of baseline measurement of the healthfulness of your diet. And in the UK, we're kind of the poor people, we've got the poorest health of nearly any nation in all of Europe. Diet or food-related ill health costs us about 98 billion a year to the whole UK economy. That's not just the cost to the NHS, but it's also the cost to business, it's the cost of sickness and absenteeism and people stopping work much earlier than they need to because their health is so poor. And we need to eat more healthy food to combat food-related ill health. The key sort of to all of that, I think, is more fruit and veg. I mean, there's lots of food we could all eat more of that would help our health and well-being, but fruit and veg is kind of the cornerstone of a healthy diet. And in the UK, well, all of us, we don't eat enough, right? The five a day metric, we've all heard it, it's been around for years. Most people from all income brackets, very few people manage to eat five a day, but it's the people with the lowest income in the UK who have the poorest consumption of fruit and veg. And it's people on lower incomes who have a higher rate and a higher prevalence to food-related ill health. And it's that dynamic that's costing the UK, UK PLC, the NHS, everybody, it's costing us a lot of money. It's creating untold misery, because not being well, being unwell, being unfit is not great. And having long-term health conditions, living with multiple long-term health conditions is not great. And growing up as a child overweight or obese is also really challenging. It has, it creates health problems, but it also creates stigma and it leads to poorer outcomes around education and and work as well. There's statistics to back that up. So, yeah, fruit and veg is really important if you ask me.
Dr Rupy: Yeah, and you know, you alluded to the five a day slogan. So, you know, it's been around for over 20 years now. I don't think there is anyone in the UK who's never heard of that slogan. And it exists in various other countries, in America and Japan have got their own, Australia's got their own. Roughly it's around 400 to 500 grams of fruit and vegetables per day. I personally include nuts and seeds and and legumes into that mix as well. Um, why, if you look at a 10,000 foot view of of the sort of pattern of fruit and vegetable consumption or lack thereof, what are the drivers behind why people just on average are not consuming enough?
Jonathan: I mean, I think there's a number of dynamics here. One is that we're really good in the UK, and globally as well, it's a phenomenon that you'll see in America, especially, you'll see it in Australia. Australia and New Zealand actually, strangely, have very high rates of food-related ill health, high rates of obesity, very similar to the UK and the United States. And that's because we're extremely good at making very tasty, very unhealthy food, really cheap, really available, really accessible, and we market it to people. We market it very cleverly at people. So we're really as a as a country in the UK, we live in a kind of a food swamp. We're saturated all around us with unhealthy food, and actually access to healthy food is not always easy. I gave you the example earlier, I was on my way here, I knew we'd be recording at lunchtime, so I thought I'll grab a healthy snack from M&S at the train station on my way, and I walked around and around the M&S trying to find something that I thought would be a healthy snack that would get me through the podcast, and I managed to come away with a banana and a packet of salted chocolate trail mix with nuts in it, which I thought was somewhat leaning towards the the healthier side. It's really difficult to to prioritize healthy food in a in an environment where we're where we're swamped, saturated with unhealthy food. On the other side, calories from unhealthy food are twice as affordable, twice as cheap as calories from healthy food like fruit and veg, right? So it makes a rational economic decision if you have limited income and you need to fill yourself up with the calories that will drive you through the day, will give you the energy for the day, you can get those calories that you need for that energy twice as cheaply from unhealthy food than you can from healthy food. So if you need to make sure, you're living on a very low income in the UK, you might be living in a food insecure environment and you want to put food on the table for yourself and your children, you can do it much more cheaply on highly ultra-processed foods that are cheap and easily available and marketed at you and your children.
Dr Rupy: I'm just thinking of that scenario for that individual or that family who is relying on the extra calories that they can afford from ultra-processed food. It's like doing a deal with the devil because what you're actually getting in return, whilst it might be more calorific, it's not going to be satiating, it won't have as much fiber or no fiber. Yes, it might have enough protein, but essentially it's not going to be giving you the nutrients. So you get into this pattern, at least I've seen anecdotally through my work in A&E and as a GP, where you are overfed, undernourished. So you can very easily overconsume those extra calories, but you're not actually sufficing the minerals, vitamins and and phytonutrients that you require from plants to actually thrive on said diet. So I I I take your point that, you know, you can get overnourished, you can get more calories and that's sort of an economic rational decision. But perhaps there's an educational mismatch there where if people were more informed about fruit and vegetables and what they're actually getting for their extra cost rather than calories, then people would make a different decision.
Jonathan: So, I mean, I think, you know, coming to the work that we do at Alexandra Rose Charity, I think you've you've pointed out an interesting dynamic. What we do at Alexandra Rose Charity is we provide Rose Vouchers, vouchers for fruit and veg that people can take to a local market and exchange for fresh fruit and veg. And so what we know is this is targeted at communities, low-income communities where that consumption of fruit and veg isn't great. And when we do a little bit of the education piece, but actually what we mainly do is we give them the money. You know, this is cash, it's conditional cash, it can only be exchanged for fruit and veg at local markets, but it's still cash really. And uh, and we give them that ability to buy more fruit and veg. And they do. Without that education piece, without even more motivation, just by having the motivation of extra cash to spend on fruit and veg, their fruit and veg consumption goes up. So at the start of the program, only 7% of children on the program are eating their five a day. By after six months, 67% of children are eating their five a day. On our fruit and veg on prescription programs, so our early years model is targeted at children in families where before they get to school. So it's all about early nutrition, getting the foundations right for the best possible start in life. Our fruit and veg on prescription program targets people in older life who have food-related health problems. And this could be multiple long-term health conditions that could be improved by access to a better diet and better nutrition. And we're seeing very similar, like at the start of that program, 28% are eating their five a day, by the end of it, 80% are eating their five a day. So it's a massive change just by giving people the financial ability to buy fruit and veg. And going back to your earlier point about, you know, just the right nutrition that they're under the the overfed undernourished. That's the phrase exactly. I think in the UK, yes, we do have food insecurity, right? We do have people who are going hungry and that's absolutely outrageous considering we're what the seventh, eighth richest nation in the world. It's crazy. Um, but by and large, um, it's it's it's uh, it's sporadic hunger. It's skipping meals, it's skipping eating for a day. What we really have, food insecurity is a good word to describe it, but I would call it nutrition insecurity. People are uh, do not have the financial ability to able to afford the nutrients that they need to survive and thrive really. And and that is because of the nature of our food system. And I think we have, you know, there's a lot of evidence coming out now that it's not about individual choice. Like people aren't choosing to have a really bad diet and and wanting, you know, they don't care about the outcomes. The the evidence is more pointing that uh that food-related ill health is a uh a a natural response to an unnatural environment. And that unnatural environment is our food environment where we are, like I've said earlier, swamped uh by the unhealthy foods which are very affordable and marketed at us. And we can't get past the marketing thing. And so, you know, two weeks ago, the government announced that they're going to to push forward with the advertising ban, the watershed advertising ban to limit the amount of junk food that is marketed at children. And that's, you know, an admission from government that that marketeering works, that targeting of children by unhealthy ultra-processed foods works and it's having a detrimental impact on their health. So they're introducing that restriction, but those kids live in, many of them live in families where they still can't afford to access the good stuff as well. And so for us, it's about making the good stuff affordable. It's about making it more available. It would be brilliant if fruit and veg had a marketing budget behind it. Imagine if you put the marketing budget of Coca-Cola behind fruit and veg. Nobody markets fruit and veg really. It's because it's not it's you can't brand it, right? It doesn't it's anyone can grow a carrot. So you can't market the carrot. But if we put money behind promoting and marketing the good food, like we do the bad stuff, wouldn't it be interesting to see what happened?
Dr Rupy: Yeah, totally. I uh, I mean, we do our best here to market fruit and vegetables as best we can on the on Doctor's Kitchen podcast and socials, but clearly we don't have the same budgets there. I I guess um, why don't why don't you give us some sort of uh some ideas as to the proportions of people, I'm not too sure if you have stats at all, but the number of people who are uh food insecure to the point where they are skipping meals and they are going hungry versus people who are on a lower uh household income, still have the ability to consume food two, three, four times a day, but are choosing the wrong foods because they're heavily marketed and because they tend to be cheaper than the healthier alternatives. Do we have any idea of like the proportions of those? Because I think sometimes for an individual listening to this on the radio or via the news, everything gets lumped together. And I think there are distinct scenarios for different people depending on household income as a as a crude differentiator.
Jonathan: Yeah, I mean it's it's an interesting one, household income, uh, because food is one of the only areas in your budget where you have flexibility. Right? So you uh, uh, you've got to pay the rent. The rent's the same every month. You've got to pay it. If you don't pay the rent, you get kicked out. You've got to pay the mortgage, you've got to pay the electric or they'll cut you off. Food is somewhere you can trade up and trade down. And it's really interesting how people do this. So we've seen this in the cost of living crisis. Cost of living crisis, fruit and veg consumption dropped quite considerably. Like it it's a statistical reality. People stopped buying fruit and veg because it's a more expensive category. It has a higher chance of going to waste, right? If you buy a bag of salad and you put it in your fridge, but you don't use it within a couple of days, it might not be there for you to use or in good condition for you to use. And so that investment has gone to waste. All of your ultra-processed foods don't have that dynamic. They can stay around for a long time and when you eat them and and consume them. So I think that flexibility in the food budget drives us all to a degree. I mean, I know when when I get to the end of the month and time times are tough, I will go to a cheaper supermarket. And if if I had my way, I would shop at the farmer's market every week, but when I walk away from the farmer's market, I notice a hole in my pocket, right? So I think the the the the challenges even though people have they're on people on really low incomes who are struggling with food or nutrition insecurity, there are people who have a fairly okay, got a lower level of income, but it's a little bit better. They're still trading down on the on the less healthy food because it helps fit into the budget constraints that they have. And especially in the last few years, this cost of living crisis has damaged people's long-term health. And that's, you know, that that's something that we're going to find out. COVID did, and then the cost of living crisis, and we're going to find out the impacts of that over the coming years.
Dr Rupy: There's a great organization called the Food Foundation and they measure at regular intervals, I think every quarter, they measure the scale of food insecurity in the UK. So June was the last time they did that data point. 7.2 million adults in the UK are technically in food insecurity, which is like you explained, missing, skipping meals from day to day to make ends meet. That's something like 2.3 million children in those households who are experiencing the same thing, food insecurity, nutrition insecurity.
Jonathan: It's one in 10 in the UK essentially.
Dr Rupy: Seems, yeah, some yeah, some very close to that. Yep.
Jonathan: Wow.
Dr Rupy: It's a huge issue. It's become it's become a a more prominent um factor of life in the last 15 years. So food banks in the UK didn't really exist before the 2008 financial crash. It's a fact. You know, Trussell Trust was not doing those food banks like they are now in 2008. Uh, that austerity, 2008, the financial crash followed by austerity has driven the rise of food insecurity in the UK. Um, that's seen the rise, the absolute mushrooming of food banks and food redistribution charities all over the UK. Then we got to COVID and that saw a huge spike again, and then the cost of living crisis. And so now we're at a point where actually there the food redistribution system is a sort of de facto part of our welfare system. It's almost a tacitly approved by government that people aren't being given enough money through the welfare system or through jobs as well, for the payment that the the low level of pay that people get through jobs isn't enough of a the safety net is not great enough and we need to have this food surplus system to pick up um where where the state and uh employment are failing. Yeah. Um, and you know, the great work that those organizations do, you know, fantastic organizations supporting people in very vulnerable positions, but we shouldn't be in that situation. And the reality is if it's about if it's a system based on food surplus, most of that food will not be fruit and veg because surplus food is it's much easier to redistribute packaged and processed food than it is fruit and vegetables. And most food banks, a lot of food banks don't have storage or appropriate storage for fruit and veg. But also, if it's surplus to requirements, generally that means it's, you know, it's not uh it's it's got a short shelf life as well. So we're not getting the best fruit and veg to people who really need really good quality fruit and veg.
Dr Rupy: Yeah. One of the the things that you mentioned to me was the cost of healthy uh items that you can find in supermarkets, farmers markets, etc. And there's a reason why they're so expensive, take a long time to grow, perishability, etc. But perhaps we could talk a bit about subsidies in the UK because to my limited knowledge around this, we heavily subsidize certain products, uh mainly animal-based products, uh dairy, meat, etc. I'm not aware of subsidies, uh the extent of those for fruit and vegetables or, you know, these health-promoting ingredients that we both love. Um, why is there a differential and and what is the state of play with subsidies uh now, particularly in a in a post-Brexit environment?
Jonathan: Yeah, it's a it's a really good question. So, I mean, I think what our work suggests at Alexandra Rose Charity, the the voucher approach is that, you know, you can put financial incentives into the system to generate public good. Now, we've always financially incentivized our food system. And that goes back dozens, hundreds of years, um, through taxation, uh, through um regulation, through uh subsidies, direct subsidies, indirect subsidies. This is part of the food system. Uh, and for many years under the um, uh, European Union, the huge part of our subsidy was directed through the common agricultural policy. Um, and mainly that paid on per acre of land. You know, it really didn't um matter much what you did with that acre of land as long as it was either in farm production or in an environmental sort of stewardship program, they would pay you for that acreage of land. Hence, very large um arable farmers who produce things like canola oil, rapeseed oil, um, uh, wheat, um, dairy producers, um, meat producers who occupy a very large amount of land got the vast majority of of subsidies. Also, the very richest land owners in the UK sucked up most of the subsidies as well. So some of the wealthiest people in the UK who were benefiting from that system. Um, horticulture, uh, where we grow fruit and veg, right? Um, generally takes up much smaller um area of land, especially if you're looking at glass houses, tomato production, for example, you can grow a truckload of tomatoes in a glass house that covers a couple of acres. Um, and they were very get basically getting very little subsidy if any because they didn't have an acreage to to claim on. So the incentivization in the UK up until recent was all around um, uh, the animal proteins and arable agriculture, which has its impacts of course, um, and not on fruit and veg by and large. Uh, we've left the European Union, uh, for good or for bad, um, but one good thing potentially from that is that we do take back control of the way that we financially incentivize our food system, the subsidies that we use to incentivize our food system. And the great news is is that the principles under what's called ELMS, the environmental land management, I think it is called, the the the legislation brought in by the last government is that it's to pay for the focus of our subsidies is now to pay for public good. And public good includes environmental stewardship, biodiversity, flood defenses, uh, but wouldn't it be great if we could extend that, that the idea of public good out to the health that is generated by our food and agriculture system. And I mean, it's a great idea, right? It's just takes it a step further. So why should you get more um subsidies just because you're um, you know, got dairy cows and you're producing milk or or meat from sheep, uh, than somebody who's producing fruit and veg, which we need a lot more of for our health and well-being. We also need a hell of a lot more of it to hit our climate targets. There's a statistic uh uh that's been bandied around recently which says that to to meet our climate goals by 2032, we have to increase um fruit and veg consumption in the UK by 30%. So that's a great thing for our climate, but if we all increase our consumption of fruit and veg by 30%, that'd have a massive health impact. And that is a amazing public good, right? So this is where climate change and health and and health inequalities are actually can be linked. You can get dual benefit by looking at them in the round. Uh, and I think, you know, increasing financial subsidies for fruit and veg within our agricultural policy would be fantastic. What I've been talking to um policy makers about is how the work that we do is a financial incentive that goes directly into the hands of consumers who need the access to that fruit and veg most. So if you could then connect that voucher to the local sustainable supply chains, that that money that you gave to a person on low income who needs an extra bit of cash and also needs more fruit and veg, would then be spent in a local market or a local shop that then would go back to a local farmer and a local supplier. And that creates the benefit, the financial incentive for growing fruit and veg in that natural sustainable local way, but the benefit for the improved nutrition and health and the financial security of that individual or that family happens at a local community level. Um, we've started to pilot that. So we're part of a national program called Bridging the Gap. And Bridging the Gap is all about trying to find where you could put the financial incentives within the system to to make healthy and sustainably produced fruit and veg more accessible and more available to people who need access to that type of food the most, which is communities who are who live with low income. We have a pilot in Tower Hamlets where we're working with um two food co-ops and the co-ops are supplied by an organization called Growing Communities and the Better Food traders. They grow fruit and veg all around Essex, around uh um the borders of London, and of course they import some from Europe as well. Uh and that is going into these local community co-ops and being sold to people using their rose vouchers. So it's an amazing uh uh trial of how this could work at a larger scale. Uh and there are a number of other trials that are taking place around the UK as part of that Bridging the Gap project. What we really want to do is show that to policy makers. So you invest one pound here and this is the benefit it has for health, well-being, community, environment, agriculture, the um rural environment, rural jobs. And you can prove. So at the moment we've got great economic impact um assessment work around the value of our program. Most of our vouchers are spent in local traditional street markets. Uh and for every one pound Rose voucher that goes through a market trader, a total of 3 pounds 11 of economic benefit is generated because people are spending money in the market, those traders are local people, they take that money, they spend it in the local economy. Those people who are going to the market, they might not have shopped at the market before, but then they start using their own money to buy from the butcher, the fishmongers, the clothes stalls. And that has a multiplier effect. Unlike spending money perhaps in a supermarket, most of that benefit leaves the local economy and goes into shareholder pockets. Whereas this, most of it stays circulating within the local community. Now if we could take that economic impact and take it a step further and make sure that money then went back through the supply chain to rural economies in the UK um to support sustainable um farming practices. Yeah. I mean that's that's a win-win.
Dr Rupy: It's like a no-brainer. I guess if I was to put my consumer hat on, right, and you um uh gave me these vouchers and I was able to spend them in local markets, doesn't that as a consumer limit my choice of fruit and vegetables um because I remember you were talking earlier about how 50, over 50% of fruit and vegetables is actually imported. So the selection of fruits and vegetables that I am familiar with and I actually want to use might actually be limited compared to if I just went to my supermarket with my regular pounds instead of the Rose Voucher pounds.
Jonathan: Yeah. I think that's a really good question. So at at the moment, the way that Rose Vouchers work is like I said, they're mostly working with traditional um street markets in London. And the great thing about traditional street markets in London and in Barnsley and in Liverpool and Glasgow, the other areas we work, is that they know their local community. And so they provide the produce that fits the cultural tastes and cultural needs of that community. So you you go to um East Street market in in Southwark and you will find um food from all over the world uh and and that's culturally appropriate for the people who are part of our Rose Voucher program. Yes, the challenge with uh UK growing and sustainable supply chains uh is that uh the diversity of produce is less. One of the focuses of um Bridging the Gap is to try and encourage, incentivize uh the growers to um to expand their range to more diverse um food categories. So we can grow more a lot of more uh uh produce from parts of Southeast Asia and Africa can be grown here. Um but the but the demand has not been it's it's not been the traditional demand so farmers aren't set up for it. So um I've heard of um uh you know, people trying to uh expand into Chinese vegetables and looking at experimentation with okra, growing okra in the UK. There's lots of examples, um but these these groups need to be encouraged to do that. Farmers need to be encouraged to do that and they need to have feedback from the supply chain. So they need to understand the the new the communities that they will be serving in the future. But I get you. I mean, I think it's I think you know, we we can't um uh conflate this movement towards um, you know, a sustainable diet with denying people their their access to the culturally the cultural foods that are appropriate for them. And you know, in in in reality, it's not those people uh in those communities who are driving climate change, right? You know, there is somebody else out there who's driving most mostly driving climate change and um buying a few yams and plantains from uh West Africa in South London is not going to be the be all and end all of of of our nature and climate emergency. And I think that's still got to be part of our food supply chain. It always will be. However, for our food security, you know, so, you know, if we're only producing 30, 40, 50, 60, 70% of our of our fruit and veg at different times of the year is produced overseas, we're food insecure as a more food insecure as a nation if there's another global pandemic which really restricts movement, if there's, you know, climate um uh challenges in Southern Spain and so they can't produce enough to export to us anymore. That food security is is really important. Um, uh, growing more fruit and veg here has benefits for our environment and our and and our health. Um, but there'll be parts of our food economy that's still global.
Dr Rupy: It goes back to the subsidy um uh point, right? Like, I mean, it's a use case for Brexit, like a positive use case for Brexit that I'm I'm really pleased to hear about finally, um, that we can say something like about a benefit. Um, but, you know, if we give subsidies to folks who are actually growing the produce, then they've got more um financial flexibility to test, you know, different crops and and stuff and they've they've got less of that slim margin that they're currently working toward, which might actually encourage them to just fixate on one particular crop or one particular sort of like, you know, they've got to do their their math and their yields. I guess the other thing is, um, you know, I I went with you to the Brixton market, you know, I I saw the the incredible um uses of these vouchers and how they were buying yam, cassava, plantain, things that I personally wouldn't buy. And you I can see that point around like having that diversity of options and ensuring that we don't take that away. Um, I so I think it's it's an important point to ensure that consumer choice, but something that everyone understands now and has been brought to light was the stress on our supply chain during uh conflict that wasn't even on our borders, during uh COVID, which obviously was global. These are all things that I think should make us realize the value of the subsidies for fruit and vegetable consumers, but also from a health point of view. And that's what I kind of want to go down dive into a bit more because I don't see this purely from uh the perspective of ensuring that people aren't going hungry. This is obviously a very, very important thing, but also the burden on the NHS. Is there any semblance of uh an economic argument uh similar to the one that you've just described of one pound spent in this local market and three pounds out to the local community, going further onto the the the reduction on the burden on on our national health service.
Jonathan: Yeah, no, it's a it's a great question. So for ourselves, we've done that sort of uh social value um economic impact assessment uh and uh I have the statistics to hand in fact, so I'll try and find them and read them out. But so yeah, so it makes sense like if you can increase people's consumption of fruit and veg, especially in early years. So we know that children, one in five children are turning up to school in the UK either overweight or obese. By the time they get to year six, so that's 11 years old, it's one in four. Something's going, yeah, one in four. So something's going wrong in those early years, right? Before they even get to school. We know that the first 1,001 days of a child's life has huge impacts on the um the life trajectory around um speech and language, socialization, education. You know, you get things right in the first 1,001 days, that sets someone's life trajectory. Huge evidence around that. It's the same with their food intake. If they eat a varied, diverse diet in early years, they're more likely to have a very diverse diet when they're older and have better health outcomes. So we've done the the statistics on that. The social impact evaluation that we've that we've done uh on our project in Southwark shows that for um the Rose Voucher fruit and veg project would save the NHS 265 pounds for every child on the program and 115 for every adult as well. So the benefits uh are are there for all to see. These are these are immediate uh cost savings to to the NHS in in the period around our work. The long-term savings that are available. So I think for this we need to look at the United States, right? So the US um have been running uh fruit and veg voucher projects now for about 20 years. They they started a lot earlier than we did. Uh and there's some very clever people over there. I mean, of course they've got high rates of food-related ill health, some probably the highest in the world. Uh and um some very clever people there in the early 2000s came up with this idea of that if you double the value of people's food stamps but encourage them to spend it on fruit and veg, would that have health impacts? Uh and they um piloted it and they had some really good results. Uh and then they evolved into their fruit and veg on prescription model, which works with um hospitals, dietetic departments and and with people who have um uh food-related ill health. So type two diabetes, overweight and obesity, and they go to their um weight management clinic and they get fruit and veg prescription that they can take to their local markets. Uh they were very successful in proving that um the uh the government has invested 270 million. Interestingly via the farm bill. So again, America is really good at subsidizing its agricultural system. Uh and these clever people in the United States managed to make the case which was if you give a pound to uh a person in low with low income or a dollar as it would have been there, um they will spend it on fruit and veg that is grown by an American farmer, which, you know, America is a massive agricultural nation. They import far fewer um fruit and vegetables than we do because of their massive production scales. Uh and the, you know, diverse climate that they have. Uh and um so the money goes back to farmers. So you've you've you've you've had the impact that you wanted to had, but you've actually helped people in need. So they now give 270 million from the federal farm budget. And that is matched locally by um states. Um states put their public health budgets in, but interestingly, by health insurance companies and hospitals. And why are they putting money in? Because now because of Medicaid and Obamacare, um the vast majority of people are now covered with health insurance in the United States. Uh and they are um if they end up ill in hospital, it costs the insurers money. The insurers have to pay for that health care. The insurers have realized that if they actually give out fruit and veg via prescription and stop that person coming back to hospital with the the impacts of their long-term health condition, they save themselves money. So they're now starting to invest. Now, the one thing you can guarantee, if American health insurers are spending money on anything, they've run the numbers, right? They know that it has an economic benefit to them and their shareholders and that's why they're doing it. So I would love to see their data. I'm sure they have it, but they don't share it publicly. Not that I've seen, but I'm pretty sure it they know from the the fact that they're investing, you know, large amounts of money in these types of programs in the United States that they know that it has health benefits that in the end will save them money. So, uh a recent study in the United States has concluded that over 25 years, um if you provide fruit and vegetables on prescription to 6.5 million US adults who are experiencing both diabetes and food insecurity, you would prevent 292,000 cardiovascular disease events and save 39.6 billion in health care costs and 4.8 billion in productivity costs.
Dr Rupy: Bloody hell. So go through those numbers again one more time, sorry.
Jonathan: So that's you give fruit and veg prescriptions to 6.5 million American adults.
Dr Rupy: 6.5 million American adults with type two diabetes who are food insecure.
Jonathan: You would prevent 292,000 cardiovascular disease events and save 39.6 billion in health care costs. But also, and I think this is really important, when you're thinking about ourselves as an economy, right? UK PLC, we always talk about this. It saves 4.8 billion in productivity costs. Because when you've got poor health, when you're managing things like overweight and obesity, type two diabetes, um cardiovascular disease and and and the and also quite often the mental health struggles that come with that burden of disease, your productivity is less. Your sick days at work are higher. You have higher levels of sick days at work. This costs the economy. So it makes rational economic sense to try and address this problem. Unfortunately, we don't seem to have the ability to tackle it head-on, right? And and you've got to ask yourself why.
Dr Rupy: I I mean, I I'm just imagining a whole bunch of GPs listening to this just nodding their head because they're at the coalface dealing with the issues of poor productivity, more sick days, etc, etc, mental health struggles. I'm just picturing that individual who's having to go to their GP because they have a chronic illness, because they are financially insecure, because uh they need to take time off work for whatever reason that might be, and we're having to deal with that, hence why GPs are leaving in droves because they're just so burnt out. So you can just see the the trickle-down effect of this lack of innovative thinking of, you know, not pointing fingers at any government or parties here, but you know, just lack of innovative thinking across the board that has led to this issue. And if we have this data already that suggests that if you invest in something as simple as fruit and vegetable uh consumption and making that easier, like it's a no-brainer. We we already have the and as you were going through the numbers, I was just trying to imagine, you know, around a third of individuals in the UK, if I'm if I'm correct, are um uh overweight or obese and that's increasing steadily. That will correlate very nicely uh or unfortunately with type two diabetes and pre-diabetes. You just talked about earlier about how one in uh 10 individuals or 10 million people across the UK are financially insecure. You can see those numbers marry up quite nicely to what the potential outcome could be or the cost saving to the NHS that's already struggling. Like three or four billion or something like that. That's about 4% of the NHS budget. That's a huge saving, you know?
Jonathan: So I mean this this is why, I mean, you know, I think it's an idea that that's time has come. Uh the National Food strategy that was published in 2022 by Henry Dimbleby. So he was appointed by the government to advise them on food strategy. He spent 18 months going up and down the country doing amazing consultations, talking to everyone from the food industry right through to the voluntary sector, um advocacy organizations. Uh and he came up with a, you know, what it was a really comprehensive plan for tackling the multi-faceted issues that we have with our food system, you know, the key amongst those is the climate and nature emergency that we that we face and the um uh burden of food-related ill health. And uh and one of the recommendations in that was to pilot on a large national scale um fruit and veg on prescription uh to to to test how this could work at scale. So you talk about the local GPs and and and and how they're struggling with managing the the the burden of diet-related ill health, food-related ill health in the UK. Um, we work with uh two um health organizations in in London, one in Tower Hamlets uh and one in Lambeth delivering fruit and veg on prescription. So this is uh a one organization is a GP led um community health organization that we visited together last year. It goes takes health out into the community, takes it to the community centers, takes it to a barber shop on Streatham High Street, um reaches out to where the people are. Uh and and the doctor who heads that up, Dr. Chichi has said numerous times uh that uh this this feels like the most impactful thing she's ever been able to do as a GP. She feels like it's, you know, doing something that's has massive benefit. And in that program, they work with people with hypertension, high blood pressure. And of the people on the program, uh seven out of 10 have seen their blood pressure reduced to a to a um more sustainable healthier level, gone from the red zone and back into the green zone. Uh and and that's a massive impact. In Tower Hamlets, I mean it's worth saying also, both these programs funded by local authority public health teams. So these are local authority public health teams who are they're getting who are dealing with the crisis around the burden of food-related ill health across their communities and they see this as as as as a an innovative way of trying to tackle it, a different way of trying to do it. So Lambeth Public Health team have funded the project in in Lambeth. Uh in uh Tower Hamlets, the public health team there, um we're working with um Bromley by Bow Centre, which is a um uh it's an integrated health center. It has a GP surgery on site and it has a community health organization on site. So the GPs there can refer to what are called social prescribers. Social prescribers is a national movement which is funded by the NHS and and and supported by the government, which acknowledges that people's the determinants of people's health are wider than just the medicine that that you might um get from the doctor and and the the the acute illness that is happening to you at that moment in time. That your health is connected to your environment. It's connected to your social situation, it's connected to your housing, to your financial situation, to your to your wider environment. And social prescribers are there to help people, um, you know, after they've visited the doctor to get maybe their metformin for type two diabetes, what other things could they do to support them to be able to make wider lifestyle changes that can benefit the the the health condition that they're living with. Um, these are people with chronic health diseases, multiple um what they call comorbidities, uh and quite often um living with uh mental health challenges. Mental health challenges come, you know, when you've got very little money as well, that is a that creates a mental health crisis as well, creates stress and anxiety which also plays back into their health outcomes. Uh and what we're seeing there is um, you know, huge improvements in health and well-being by prescribing fruit and veg. We're seeing a reduction of 60% in GP visits from that cohort. A fall of 60% in the number of times they visit the GP. These are people who go to the GP very regularly because of the multiple and complex health needs that they have. Reduced by 60%. You think about the savings to the NHS of that reduced um the number of visits to the doctor, just on the waiting list on that doctor's surgery so that they can see more patients who need access at that time. It really um helps. Now, fruit and veg increased consumption is super important, right? But the the the holistic part of this project is that it's not just the I always say the program is a literal and a metaphorical carrot, right? So you you go along to your GP surgery or in the early years model, you go along to the children's center, you get a voucher that you can go down to the market and buy a carrot. But next week you go back to the children's center or you go back to the GP surgery, you talk to the social prescriber to get your next voucher, and in doing so, that social prescriber goes, how's your week been? What things or challenges have you got going on? Oh, the housing stuff hasn't been resolved. Let us talk to your housing management organization and see what we can help you with. You need some more debt advice. Let's get your debt advice. So all of that, let's do maximum income maximization. That's a really key thing. So many people aren't accessing the benefits that they're eligible for. Um uh and so if you increase people's income from benefits, that reduces stress and anxiety because they have better financial situation and that stress and anxiety plays back into their health and well-being. So the the carrot is good for them, but that carrot, that incentive to come back and engage with services week after week is also part of the change that happens.
Dr Rupy: I love that. I love the the metaphorical and literal carrot. That's the way I've got it in my mind now because you're right, it's not simply, as much as I'd love to believe that it's just the fruits and vegetables that are creating this 60% reduction in GP visits, it's going to be the interaction, that community feel, the fact that you feel that you're supported as well by the services that you're eligible for, um and actually that you know, that that engagement um as well. You've hit a recent milestone of a million pounds worth of vouchers. Is that is that right? In the last year?
Jonathan: Yeah, so we've just we're we've just passed the 3 million mark in total. So we we started doing this in 2014, very small, um just a couple of pilots in Hackney and East London. Uh that's grown out, it's taken quite a few years, but it's spread out now. So we're in five London local authority areas. We're in Barnsley in South Yorkshire, Liverpool and Glasgow in Scotland. Uh it took us uh it took us about seven years to do the first million vouchers. I think we did the celebrated the first million in 2019. Uh and uh and it took us about 18 months to do the second million and it took us just over 12 months to do the third million. So the scale has has really grown.
Dr Rupy: So the graph, if you imagine, is just going up and up.
Jonathan: Yeah. And and that's that's testament to the amount of need that there is out there. So, you know, this is this this this has grown substantially uh after because of COVID uh and because of the cost of living crisis. Uh but also it shows that it's a model that people are starting to realize is is a different way of addressing the problem around food and nutrition insecurity that's slightly different to the surplus supply chain work that food banks do. Because if you're a local authority area, you're trying to address the levels of need in your community, but you want that to be sustainable. So you want, first and foremost, you want the food that they're consuming to be as healthy as possible. So the vouchers do that because it's fruit and veg. But then that voucher goes back into the high street, which is the high street that that local authority manages. And so like we said earlier, if if every voucher is worth 3 pounds 11 in total economic benefit to that local community, the local authority is going, well, this this makes sense. I'm putting a pound back into the pockets of my residents and that pound goes back into the pocket of the high street and then it generates extra income for the high street. It increases footfall on the market, increases use of the high street, keeps people out of the shopping mall and the supermarket and puts money circulating within our local economy. So they get it from both the health and well-being angle and the local economic regeneration angle, um but they're look but they're looking for different ways of making making a difference uh that they think can be, you know, good in the round and more sustainable. Uh and that's why we've seen income in recent years, we're seeing increase in income from local authorities who commission our work. We raise funds as a charity, right? So we're out there asking people for funds every day to try and help us support our work. So we raise money from trust and foundations, corporates and individuals. But we also um expect at least 30% of the match funding to come from local authorities. And every local authority manages that 30% and in many cases they exceed that well exceed it. Um and that's because they see it as a valuable investment. They also see it as a valuable investment because like we talked about the literal and metaphorical carrot, they want people to be accessing those services and they want the people who need access to those services most to be accessing them as most regularly. So so they are helping get the carrot, they're helping put the money back in the local economy, but they're helping their residents engage with the services that they support like children's centers, community health organizations to get the wider wrap around benefit of the whole of the whole program. It's a challenging uh external environment. Uh there is a change of government though and you know, we're starting to see like maybe some space here opening up. Uh the the last government had committed to bringing in the watershed for advertisements of unhealthy foods um targeted at children. Uh they they had that policy but they delayed it and delayed it and now kicked down the road because of the cost of living crisis. They didn't want to be penalizing, seen to be penalizing people. Uh they have um resurrected that uh and it's now going to become uh uh law, which is good news for on that marketing front. Um we had a very successful sugary drinks industry levy um uh uh put in place by the last government in 2015, which has generated a huge amount of income uh for tax revenues that can has been spent on some initiatives to promote health and well-being. Uh there's a great opportunity to extend that sugary drinks industry levy to other product categories, um and maybe include it things like salt, you know, high salt products as well, and generate even more income that allows the government the flexibility to spend on the type of public health initiatives that we need a lot more of if we're going to tackle um this food-related ill health crisis that we have in the UK. So, you know, we're doing a lot also to try and get the message to government, right? So we're trying to take the impact evaluation studies that we've done, you know, and and and knock on the doors of MPs and uh and parliamentarians and and uh and local authority leads and the mayors across all the metro areas in the UK, trying to put this in front of them to say, look, this is a different way of approaching things.
Dr Rupy: Yeah, and and it's in there's the economic incentive as well. If you've got the data to demonstrate that the local authorities that uh use your schemes actually generate more income. I mean, that's that's like a no-brainer. And I guess, you know, as we bring this this chat to a close because I feel like I could talk to you about the wider sort of uh food system for a lot longer, but if you if you were to to to describe what your north star is, like what what do you what when I mean, you're never going to get to a point where you can sit on your armchair at home and just feel like I've done my job. There's always going to be work to be done, but if there was something that you were aiming for in terms of the scale of your operation, how many uh how many local authorities you're in, whether you're actually part of the NHS, um in the same way social prescribing is, maybe fruit and vegetable prescribing should be a thing of itself. Like what what does that look like? Paint that picture for for me and and the listeners.
Jonathan: Yeah, I mean, I would love uh uh for us, I mean, my my ultimate aim or ultimate um vision would be for to every for everyone to have access to healthy and affordable food where they live, right? And that I think will have huge benefits for for for the UK, for people's health and well-being, for our food system, our food economy, our climate and and nature, biodiversity. So how do we get there? Uh and I think there are a number of um clear steps for for us as an organization. I don't want us just to replicate Rose Vouchers in every town and city across the UK. Uh because I think, you know, that you'd never get there. You'd we as a charity, we'd never address all of that need. Uh and there would be huge amounts of unmet need. We need to change the food system and the way that that happens is through influencing um the people who have the the levers uh for making change within that food system. So it's about taking our evidence base uh and influencing those people who have control of food policy, the food subsidies that we we talked about. How do we financially incentivize our food system to create the outcomes that we want? And it's not just about higher production levels and more, you know, more uh more money in the in the for for food industry people. It's about uh making it the food system work for everyone here in the UK. So for us, uh we're we're it's a good timing for the question. We're in the process of developing our five-year strategy, which looks at the sort of medium term, right? So that's my ultimate goal. Everyone has access to healthy and affordable food in their local community. Uh the the the medium-term steps that we need to take, uh we need to we we've got local authorities knocking on our door, so we are going to expand. So we've got some some really, really strong interest both in the early years model and in fruit and veg on prescription, and we'll see that will see us working in new areas across the UK in the next couple of years. Uh at the same time, we'll be taking that evidence base to government. I think we've got a great opportunity with the to revisit the national food strategy. Uh Henry Dimbleby's work, I think was an exceptional piece of work. You know, it's not often that government actually surveys the whole territory and brings people together. And you know, people from the food industry all the way down were very supportive of it. One thing you'll find in the food industry is that they they just want a level playing field. They don't want to lose out um competitive advantage. So they're not going to change themselves because if they change, they reduce sugar or they um reduce the ultra-processing of their food, their competitor will just take it will just flood into that vacuum left and take up the money. Um they they, you know, you've seen it from the head of Danone uh and I think Unilever have all called for more government regulation to create a level playing field um for for the food industry. So I think uh that will be really helpful if we can get Henry Dimbleby and his ideas back into the heart of government. And there is noises uh out there that he that the the current government thinks of his work very highly and are seeking advice and guidance from him. For us, that means piloting, you know, getting the government to really invest some money. And the national food strategy only recommended 6 million of investment to pilot in seven areas around the UK. That's peanuts, right? Healthy peanuts without the salt maybe. Um and and uh we would really like to see the government uh try and do that. Uh we also think the government has a um the the the last government set up these things called family hubs. Um you remember Sure Start, the Labour government program, fantastic program of work, um which basically set up Sure Start centers in communities all across the UK where to give children the best possible start in life and they were incredible resources when they were set up and they had so many programs going on. And they've morphed over time into children's centers and then the last government invested in them and turned them into family hubs. Big investment, central government investment, 300 million going into family hubs. This government is likely to continue with that work. They should allow, there's about 50 million of that money that's put towards improving infant feeding. Um at the moment, that the Department for Education won't let them spend that 50 million, any of that 50 million on supporting Rose Vouchers. It would really make sense if we could convince Department for Education to allow those local family hubs, many of whom we already work with and many of whom asked their grant manager at DfE if they could use the money to to fund Rose Vouchers. Um that that was declined. I would love to see that decision reversed and and the ability for family hubs to spend the money in that way.
Dr Rupy: We're going like back to the um the the numbers, the sheer number of people who are financially insecure. I mean, I would have thought, and you know, I'm I'm not heading up your organization here. I just want to caveat that, but I I just want I would just want my north star metric to be everyone who's in that situation has access to Rose Vouchers. I know you don't want Rose Vouchers to be like painted up and down the country because, you know, the wider mission is affordable food that people can buy in their locality. Um, but that's surely got to be a stepping stone towards that. And that wouldn't that be a great metric that, you know, out of the financially insecure people across the UK, X percentage of them have access to Rose Vouchers and we want to steadily push that up further.
Jonathan: Are you working in cahoots with my chair of my charity? Because she she keeps asking me that question. She keeps saying, what's your percentage? What percentage? Okay, what's the unmet need? How what percentage are we going to set as our north star?
Dr Rupy: That's the way my brain thinks.
Jonathan: No, and I mean, I think you're right. And you know, until until we can get government to make concrete shifts, you know, like we we want, I think we talked earlier about, you know, wouldn't it be great if UK could become one of those blue zones, those places where everyone eats so healthily, they live really long and fulfilled lives, right? We have a long way to go, right? So if we could be like a half a blue zone, what's half a blue like a light blue zone. It would be a massive shift change for us as a country. Um and how do you incentivize that food systems change? You've got to put the money in somewhere and yes, I think Rose Vouchers is a good way of doing that because it puts money into people's pockets and they need more money, right? People are really struggling. If we can find a way to give people more money, that's really good. But that money is then going into incentivize the type of food system that we all need. So yes, I mean, if we have Rose Vouchers in as many communities as possible and we can meet 30, 40, 50% of that unmet need and then tell the government, this is what you need to do around the rest of it to make the step change, the systems change that we need, that would be great. And having a government that's open and uh thoughtful and and understands the dynamic and is can be a little bit free themselves a little bit from the influence of the food industry, uh would be terrific and let's hope that's what we're going to see over the next five years.
Dr Rupy: Yeah, yeah, absolutely. Jonathan, look, I love your work. Um I'm just such a passionate supporter of what you do. It's amazing to see the progress in the short amount of time that I've I've known you and the organization and I I honestly feel like we're at a tipping point and I and I feel like you are going to hit those 30, 40, 50% uh numbers that your your chair is asking you for. So this is brilliant. It's brilliant to hear and um look, we'll have to have you back on at some point in the future to to monitor your progress. So I appreciate your time and I appreciate your work massively.
Jonathan: Brilliant. Thanks Rupy. Yeah, thanks for having me. Great.
