Report of: Katie Latchford, Maidstone Borough Council on behalf of Childhood Obesity Task and Finish Group

To: West Kent CCG Health and Wellbeing Board

Subject: West Kent Childhood Obesity Task and Finish Group

Classification: Unrestricted

Summary

Following its August 2013 meeting this Board requested a number of Task and Finish Groups were established, to review how collaborative working and a co-ordinated provision of services can better address specific causes of ill health.

This is the final report of the Childhood Obesity Group on how it met its aims and identified areas for future multi-agency work.

1 Introduction

1.1     The Childhood Obesity Task and Finish Group agreed to focus on the broadest definition of childhood obesity through concentrating on a system wide approach across the life course of the ‘child’ – i.e. -9 months to 18.

1.2     The group remit included:

· Developing a sound common understanding of the issues related to childhood obesity

· Developing an understanding of cross organisational issues i.e. planning, transport, health and care, levels of physical activity which contribute towards obesity prevalence at population level

· Articulating clearly how different organisations are linking up to resolve the issue

· Reporting to the board issues that are barriers

· Developing a plan of action that will resolve the identified issues

· Making strategic recommendations to the board that require senior support

· Underpinning recommendations with sound evidence.

1.3    The membership of the group included representatives from both delivery and commissioning partners; these included representatives from:

· Kent County Council (various including Public Health, Children’s Centres, Early Years, Sport)

· Midwifery, MTW

· Health visitors

· Breastfeeding, CIC

· Kent Community Health NHS Trust

· Maidstone Borough Council,

· Tonbridge and Malling Borough Council

· Tonbridge Wells Borough Council

· Sevenoaks Borough Council

2 PROGRESS

2.1    The group mapped intervention and outcomes across the life-course identifying 6 key areas for focus, these were:

· Pre-conception and maternity

· Health visiting

· 0-5/ children’s centres

· Primary school age

· Secondary school age

· Family

The draft mapping is attached at appendix 1.

2.2     Interim findings presented at the December 2013 meeting of the West Kent health and wellbeing board included:

· Work on childhood obesity needs to focus on early intervention and prevention with families and children aged 0-5.

· Support should be given in pregnancy to those women identified as having a high BMI.  There is currently a minimal service offered in West Kent and no consistency in referrals or support across the area.

· There needs to be more consistency and clarity on referrals following the 2 year check where children are identified as overweight or obese.  Currently referred back to GP, onward referral and support not monitored or reported – pathway needs to be clearer.

· There are currently no comprehensive 0-5 preventative services and thought needs to be given to how we deliver this in partnership, including weight management for under 2s and services for under 5s.

· Work needs to be undertaken to support professionals across the sector in challenging where obesity is present in a child or family, and giving consistent messages and advice.

· Current child weight management pathway is not working for under 5s and further work needs to be undertaken to identify the barriers for older children and adolescents.

2.3    Work to address and distil these down to key priorities for action was the focus of the last 3 meetings.

3.      CONCLUSIONS: Gaps in Service, Barriers to Success and commissioning opportunities

3.1     In identifying and attempting to address existing barriers, the group drafted the plan at appendix 2.

3.2     The plan raised 3 overarching principles:

3.2.1  There is a need to commission a pathway and associated services for childhood obesity that represents a whole system approach across the early years of the life course; that identifies and understands the different pressures that come in to play at different ages and can flex accordingly.

3.2.2  Work needs to be developed to identify a coherent lead for commissioning this stream of work that bridges the differences in practice and contracting between midwifery, health visiting, primary care and those who commission and delivery services focused on specific age and geographical criteria outside of the ‘health’ sphere.

3.2.3  Communication is key – be that communicating information on programmes that are available, communication between different parts of the system, communicating referrals and results; or communicating with children or families about obesity.

3.3     The action plan also highlighted the barriers identified and commissioning needs as a consequence. In summary, the group identified the following barriers and gaps in service provision in West Kent:

3.3.1  There are currently no comprehensive services provided for pregnant women with a high BMI.  There is patchy provision and local pilot projects, but comprehensive contracted provision is not there.

3.3.2  The provision of breast feeding support in West Kent is not consistent across the area.

3.3.3  There are no weight management services for children under the age of 5 and for all ages access to tier 3 services are not available unless there is illness or co-morbidities present.  Current referral processes from front line/ primary care to specialist services are not clear, and a feedback loop is not present.

3.3.4  There are currently gaps in colleted data on childhood obesity as no comprehensive data collected on young children’s referrals or outcomes.

3.3.5  The current pathway for weight management in children and young people is not functioning as it stands.

3.3.6  There is a gap in commissioning and coordinating weight management services across the early stages of the life course between partners at all levels; universal, tier 2 and tier 3.

3.3.7  Professionals at all levels still feel that they are not able to talk to children, young people and their families on weight issues.

3.3.8  There are currently no specifically commissioned services for weight management in adolescence.

4. RECOMMENDATIONS

4.1 The West Kent Health and Wellbeing Board are asked to consider the following recommendations in light of the barriers identified by the task and finish group listed at 3.3.

4.1.1 Consideration is given to the provision of specialist services within the midwifery contract for women with a high BMI during pregnancy.  This should be linked to services provided by GPs and health visitors through the 6 week check and information shared to increase referrals to community weight loss programmes post-partum.

4.1.2 That all partners support and link in to the new Breast Feeding Service that will be in place in West Kent by October 2014.

4.1.3 That consideration be given to commission comprehensive services for weight management for under 5s that complements existing provision from health visitors, but provides a coherent pathway from community based provision to specialist services at tier3.  A review of specialist services provided to obese young people is undertaken, including criteria, referral routes and pathways. That consideration is given to the provision of a comprehensive specialist service for obese children and young people and funds sought from across the system to commission appropriately.

4.1.4 That work is undertaken  with the Kent Public Health Observatory to establish what data is collected, what data could or should be collected and what data best represents the efficacy of work to reduce childhood obesity to provide a comprehensive evidence base.

4.1.5 The current pathway is not functioning well, with a disconnect at certain points.  A simplified healthy weight pathway is being developed through the local NCMP operational groups to cover local universal provision to specialist services.  Care needs to be taken to ensure that the pathway covers the whole of the life course of the child.  Also the pathway needs to cover all (not just medical) work that is being commissioned to reduce childhood obesity i.e. work to limit access to take aways near primary schools; provision of sport and physical activity in children’s centres, schools and community based settings; work on community engagement and healthy cook and eat programmes.

4.1.6 The task and finish group attempted to map any and all services that were provided by other partners to tackle obesity in children and young people.  It became clear that individual parts of the system were commissioning limited services to tackle childhood obesity, but these were not coherent or joined up.  Work needs to be completed to identify a lead commissioning body for services to tackle childhood obesity across the life course and system, so that there is an overview of services that are commissioned within and outside the ‘health’ sphere.  This might be the children and young people’s commissioning function, or the newly established West Kent level COG that is now a sub-groups of the West Kent Health and Wellbeing Board.

4.1.7 Issues were raised by professionals from all parts of the system that do not want to or do not feel equipped to talk about weight with children and families.  Training should be identified and commissioned to support professionals in talking about weight issues.  This should include elements of the NICE behaviour change guidelines and motivational interviewing.

4.1.8 Whilst the task and finish group identified the lack of services specifically for adolescents as a gap in provision, on consultation with KIASS and other agencies providing support to that age group, they felt that commissioning weight management interventions was counter productive as issues often stemmed from very complex emotional/ psychological issues.  Further work needs to be undertaken to commission appropriate weight management interventions for adolescents that are agreed by all commissioning partners.

Mapping childhood obesity interventions and outcomes

DRAFT: Childhood obesity barriers and actions

Key points:

Can we commission a pathway and associated services that represent a whole system approach across the early years of the life course which identifies and understands the different pressures that come in to play at different ages and is able to flex accordingly?

Work needs to be developed to identify a coherent lead for commissioning this stream of work that bridges the differences between midwifery, health visiting, in to primary care and those who commission and deliver services focused on specific age and geographical criteria.

Communication is key – be that communicating information on programmes that are available; communication between different parts of the system; communicating referrals and results; or communicating with children and families about obesity

Barriers identified	Action taken	Barriers still existing	Commissioning need/ who leads
No comprehensive services provided for pregnant women with a high BMI	Tunbridge Wells currently running a pilot to run a 6-8 week course in children’s centres (Tunbridge and Cranbrook) Not identified any areas of specific need.	Current provision of specialist midwifery services limited to a maximum of 3 hours per district, with coverage patchy.	Need to increase provision of specialist midwifery services to women with increased BMI. Need to link service in to health visitors who can refer and signpost in to T2 services delivered by Districts in West Kent. 6 week check as primary first referral point, however unclear if GPs are happy to speak about weight to post-partum women.
Comprehensive provision of breast feeding support across WK	Tender for new service about to be released (07 April 2014) with decision on providers being taken in May and new service fully in place by October. Baby friendly initiative being rolled out across Kent. Health visitors providing universal services - new leads now appointed.	Problems with data collection from 6-8 week check.  2 key issues are that data is not being submitted/ collected correctly.  Firstly, data is not passing from practices to child health records and secondly that data is not accurately recording breast feeding status.	Are GPs the right people to complete the 6-8 week check, or are health visitors better placed as they were historically. Is there are need to commission training for GPs?
T1 & T2 no service provision for under 5s	Mapped pockets of provision that are being piloted by districts and providers: Maidstone is piloting a sporty kidz programme run with ‘fire fit’ in children’s centres Maidstone is running a pilot with Active kidz in private nurseries focused on increasing physical activity and reducing obesity through healthy eating Maidstone and Sevenoaks are piloting a project with south east dance that focuses on family physical activity and developmental play Maidstone, Tunbridge Wells and Tonbridge and Malling are working with Little Stirrers to deliver family cook and eat courses in children’s centres, primary schools and community settings.	All work described in action taken are ad hoc programmes commissioned by Districts – not systematic commissioned approach in west Kent.  There is no centrally commissioned approach to providing early intervention services for obese children and their families. Still issues of who leads what and who commissions what – not finding duplication, rather that there is little or no commissioning of scaleable services.	Need to identify a lead commissioner for T2 services for obese children and their families under 5.  To be commissioned alongside universal services that run with midwifery and health visiting. This should be the children and young people’s commissioning function; however it was questioned whether this was in fact working in West Kent.
T3 no service for under 5s unless co morbidities / illness	In developing the current pathway for children (5+) discussions with paediatrics highlighted that there was not the capacity to offer paediatric and dietetic services to children and young people who were only obese, there had to be illness or co-morbidities for services to be offered.  No services were offered to those under 5.		The possibility of a comprehensive service for children and young people at T3 needs to be investigated and funds sought from across the system to commission appropriately.
T3 no coherent services for children from primary care through to dietetics/ peads	Current referral pathway identifies the need for referrals to be made from primary care through to Paediatrics/ dialectics following concerns raised, however it is clear that services are not available for many children and young people to be referred in to.  Data collection and feedback is also problematic with primary care professionals reporting that they are not able to see the progress of any referrals made to services.		Following on from the above, referral routes and data collection need to be improved to allow all parts of the system to analyse the efficacy and value for money of any interventions put in place.
Referral routes/ reporting not clear	Discussions with key people to understand how the system works currently and the referral routes for obese children and their families	A key barrier identified was that where concerns were raised at the 2 year check by health visitors regarding a child’s weight, they were referring the family to the GP.  There was no follow up to check that the family had attended and discussed the issues with their GP.  Even if they had, it has become clear that the referral route available to the GP to paediatrics and dietetics is not clear and that services are difficult to refer in to in their current form. There are also concerns that the 2 year check is still patchy in some areas of West Kent.  This means that a child may not be assessed in terms f their weight until the NCMP measurements in year R.	A lead needs to be identified to work on developing a clear referral system for obese children that ensure follow ups are taking place.
No coherent pathway/ commissioning model esp. through the early stages of the life course	The current pathway was discussed at length and gaps identified. A simplified healthy weight pathway has been developed that allows flexibility to show local delivery.  This has been developed through the local NCMP operational groups (which focus mainly on school aged children) who have done a very good job of bringing people and services together to understand what is out there.	There is still a ‘disconnect’ in referrals at certain points.	Sense check the new pathway to see if it has solved any of the barriers identified through this process.  Look at replicating the simple governance seen in the NCMP operational groups to enable coherent commissioning across the system.
How do we link/ coordinate commissioning outside of our control i.e.: · KIASS · Children’s Centres · Education · Midwifery · Health Visiting · School nurses	Attempted to map any and all services that were provided by other partners to tackle obesity in children and young people	It became clear that individual parts of the system were commissioning limited services to tackle childhood obesity, but these were not coherent or joined up/	Identify a lead commissioning body for services to tackle childhood obesity across the life course and system, so that someone has an overview of services that are commissioned within and outside the ‘health’ sphere.  This might be the children and young people’s commissioning function, or the newly established West Kent level COG that is now a sub-groups pf the West Kent Health and Wellbeing Board.
Primary care information in and information out	All local services for weight management (currently commissioned 5+) are now on DORIS so that GPs are able to make informed referrals.	Still issues with professionals from all parts of the system that do not want to or do not feel equipped to talk about weight with children and families.	Training identified to support professionals in talking about weight commissioned and delivered.  TO include elements of the NICE behaviour change guidelines and motivational interviewing.
There are no T2 weight management services for adolescents	Spoke to KIASS and other agencies providing support to adolescents.  They are not currently commissioning weight management interventions and not planning to as they feel that a focus on weight is counter productive as issues often stem from very complex emotional/ psychological issues. There is no commissioning specifically focused on adolescents from KCC Public Health.	There are no T2 weight management services for adolescents	Investigate the possibility of commissioning a partnership service across the agencies involved which tackles the mental and physiological issues of weight management for adolescents.  Funding for this will need to be sought from across the system which will be difficult.
Communication issues – no one understands each others programmes	Investigated the possibility of more closely unifying commissioning so that a universal service is available across West Kent and scaleable to Kent level.	Still issues as complex landscape of commissioned and universal services provided which is difficult for professionals to navigate	Investigate commissioning a single point of referral that is able to take referrals from all people and direct to the most appropriate services.