How the government can tackle obesity

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MEND, a social enterprise that runs obesity treatment and prevention programmes for families, puts forward its recommendations for the government’s forthcoming obesity strategy, due in the spring.

Last month, the Department of Health brought together experts and stakeholders to gather views on what they should be doing to tackle obesity and shape the forthcoming obesity strategy due in the spring. Chief executive, Harry MacMillan, and strategic partnerships director, Phil Veasey, were there to represent MEND’s views.

Here are the key recommendations we have made to the Department of Health regarding the strategic direction obesity policy should take, and what practical measures a government strategy should include, taking into account the direction of travel in public health and NHS policy and building upon actions announced in the respective white papers.

With regards to strategic direction, policy should:

• Redress the imbalance between prevention and treatment

Over the past 10 years we estimate that approximately £50m has been spent on evidence-based treatment of child obesity, while £1.5bn has been spent on preventative measures such as trying to improve nutrition, and increase levels of physical activity. While it is widely agreed that prevention is better than treatment, there is very little evidence to suggest that many of these preventative measures work. In contrast, there is much more evidence to support targeted prevention and targeted treatment such as weight-management programmes. These have a direct impact on slowing, and in due course reducing, the rate of growth of chronic diseases associated with obesity such as Type 2 diabetes, cardiovascular disease, strokes and some cancers.

The obesity strategy presents an opportunity to redress this imbalance. While both treatment and prevention are important, in the interests of ‘doing what works’, the obesity strategy should include a heavier focus on targeted prevention and treatment than has previously been the case. Budget allocations should reflect this.

The case for cost-effective, evidence-based, weight-management programmes is far more compelling than that for many preventative measures. If the balance of spending is addressed, and some of the sums currently spent on primary prevention reduced, then this rebalancing alone can save more than enough money to fund the entire strategy and any short-term interventions to address transition-related discontinuities – with far clearer outcomes than are currently visible. We are seeing increasing numbers of tenders for operating bundles of obesity prevention/wellness services, many of which appear to have a limited evidence base but are legacy services. A more rigorous case should be made for their continuation in the face of current funding pressures.

• In the short term, prioritise those life stage groups we can reach cost-effectively

The public health white paper rightly adopts a life stage approach to public health rather than treating individual groups and risk factors in silos. However, from an intervention perspective it is important to think not only about the different life stages, but also about the channels through which we can reach each life stage group. It is right that new types of interventions and channels such as Health Checks and Healthy Towns be explored, but it is important to invest, in the immediate term, in the interventions we know to work, through existing channels. The obesity strategy should therefore focus on adult weight management, and the early years and children, who can be reached through schools and in the community, and for whom we have proven interventions.

• Drive an approach to cross-government working

The obesity strategy should identify areas where different departmental agendas converge and there is scope for cross-government initiatives to achieve multiple objectives. MEND has been working in partnership with leisure training provider Lifetime Health & Fitness, and leisure centre operator, DC Leisure, to deliver the Community Activity Leader (CAL) project, funded by the Department for Work and Pensions’ Future Jobs Fund. The project is supporting 150 young adults aged 18-24 who have been unemployed for 6-12 months, and are interested in health and fitness, into an employable position by providing on-the-job training and an opportunity to gain relevant qualifications and work experience. These young people are placed as community activity leaders (CALs) for six months, undertaking targeted outreach activities to improve health in their local communities.

This is a nascent example of how we are tackling worklessness while growing the grassroots public health workforce and awareness. The obesity strategy should look for other opportunities to tackle society’s problems in this joined-up way.

• Support approaches which bring added value to entire communities

The positive impact of community-led obesity interventions goes far beyond the weight and wellbeing of participants. For example, MEND programmes also create opportunities for people outside full-time employment to develop skills, experience and self-worth. The obesity strategy should set out plans to support and evaluate approaches to obesity management which show the impact that community-led programmes can have on the entire community. In addition, spend on targeted treatment interventions, such as child weight management, can be leveraged into community primary prevention, so ensuring better value for money and a more joined-up approach, including peer health advocacy in schools, communities and workplaces.

MEND believes the strategy should take the following practical steps:

• Continue the legacy of action

Various initiatives have worked well to date and these should be continued. In particular, MEND supports the National Child Measurement Programme (NCMP). Not only has it contributed to the growing evidence base on childhood obesity, but it can also work very effectively as an additional channel through which children who are overweight or obese can be directed to appropriate interventions. For example, Preston City Council Sports Development, in partnership with NHS Central Lancashire and Serco, has piloted referrals to MEND as part of their NCMP strategy and it has become central to the Healthy Weight Care Pathway.

• Make it easy for commissioners to procure high-quality interventions

A commissioning support pack – specifically for obesity services – should be developed to support Primary Care Trusts (PCTs), and then local health and wellbeing boards and GP consortia, in working together to commission obesity services.

The support pack should build on existing good practice and include:

• high quality obesity pathways – enabling commissioners to determine the nature of services that they may wish to commission. There are many good local examples of this that can be publicised.
  
• benchmarking data – allowing commissioners to both assess the relative need of their population and the relative performance of existing and candidate providers (see NCMP data above).
  
• suggested proxy outcome measures – providing a framework to performance-manage providers on clinically relevant indicators rather than process measures (See National Obesity Observatory (NOO) Standard Evaluation Framework (SEF))
  
• cost data – setting out (in the absence of a national tariff) what would be a reasonable cost for obesity interventions, when commissioning at scale is the most cost-effective option, and what that scale should be. The Department of Health can gather this information in a comparable way nationally and publicise it.

Most of this can be collated swiftly from existing sources and we are happy to contribute in any way we can.

• Ensure commissioners and providers use a national set of evidence

It is important that commissioning decisions are made on high-quality evidence. In the past we have seen tender processes drag out for up to 12 months, caused partly by commissioners developing their own set of evidence. Building on the work previously carried out by the National Obesity Observatory, the evidence base should be collated and made available through the NHS Evidence website, allowing commissioners to easily access consistent, high-quality, information.

• Produce a clear set of standards by which to evaluate providers

To date, relatively few child weight-management tenders have included the ability to compare value for money on a like-for-like basis. To ensure high quality services are commissioned and provided, both providers and commissioners must know the standards of service expected of them, and commissioners must be able to compare providers like for like.

• Produce a directory of obesity providers

Given the developing nature of obesity intervention provision, it will be important to support commissioners in identifying suitable ‘any willing providers’. A directory of obesity providers should be developed, encompassing NHS, private sector and social enterprise providers. This should also set out which choices of interventions should be guaranteed to all patients.

• Incentivise good practice

Too often in the past the obesity services have been evaluated based on process and inputs, rather than on clinical outcomes. We believe this is fundamentally wrong. The strategy should set out how services and commissioners could be rewarded on the basis of the outcomes that they deliver. This incentivisation should be realistic and based on evidence, not, as demonstrated in one tender recently, putting a very large proportion of the contract at risk for outcomes far beyond those demonstrated anywhere in the literature. Mechanisms for achieving this could include use of the health premium, Cancer Quality Improvement Network Systems (CQUINs) type schemes, or the development of best practice tariffs. A NICE quality standard for childhood obesity should be developed, and children’s indicators should be included in the new Public Health Outcomes Framework.

• Lead by example

As the UK’s largest employer, the NHS has a tremendous opportunity to tackle obesity by improving the health of its own workforce, whether it is through awareness-raising, or implementing other workplace wellness initiatives. We would be happy to discuss this further.

• Build on what works, don't reinvent the wheel

Promising interventions should be nurtured and actively improved. Best practice should be spread more efficiently. Funds should be spent on evidence-based and evaluated approaches, not reinventing the wheel where there is no need to do so.