Early years high impact area 4: Supporting healthy weight and nutrition

Question 1

The role of health visitors

Accepted Answer

Health visitors as public health nurses use strength-based approaches, building non-dependent relationships to enable efficient and effective working with parents and families to support behaviour change, promote health protection and to keep children safe.

Health visitors also undertake a holistic assessment in partnership with the family, which builds on their strengths as well as identifying any difficulties. It includes the parents’ capacity to meet their infant’s needs, the impact and influence of wider family, community and environmental circumstances. This period is an important opportunity for health promotion, prevention and early intervention approaches to be delivered. Working with parents and families, health visitors identify the most appropriate level of support and intervention for their individual needs.

Question 2

Healthy Child Programme

Accepted Answer

The Healthy Child Programme offers every family a programme of screening tests, immunisations, developmental reviews, information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.

The Healthy Child Programme is universal in reach. It sets out a range of public health support in local places to build healthy communities and to reduce inequalities. It also includes a schedule of interventions, which range from services for all through extra help to intensive support.

The Healthy Child Programme is personalised in response. All services and interventions need to be personalised to respond to families’ needs across time. For many families this will be met by the universal offer. More targeted, intensive or specialised support and evidence-based interventions should be provided early to meet ‘predicted, assessed and expressed need’ to improve outcomes.

Question 3

Improving health and wellbeing

Accepted Answer

The high impact areas will focus on interventions at the following levels and will use a place-based approach:

individual and family
community
population

The place-based approach offers new opportunities to help meet the challenges public health and the health and social care system face. This impacts on the whole community and aims to address issues that exist at the community level, such as poor housing, social isolation, poor or fragmented services, or duplication or gaps in service provision. Health visitors as leaders in public health and the Healthy Child Programme: Pregnancy and the first 5 years of life are well placed to support families and communities to engage in this approach. They are essential to the leadership and delivery of integrated services for individuals, communities and population to provide RightCare that maximises place-based systems of care.

Individual and family

The universal reach of the Healthy Child Programme provides an invaluable opportunity from early in a child’s life to identify families that need additional support and children who are at risk of poor outcomes. Health visitors have a crucial leadership, coordination and delivery role within the Healthy Child Programme. They work with key partners to deliver a comprehensive service.

Health Visitors play an important role in promoting healthy lifestyles and providing consistent healthy weight messages. Promotion of healthy weight starts in pre-conception, which offers opportunities for general practice nurses, contraceptive and sexual health nurses and midwives to offer support to women to achieve a healthier weight and be physically active. Health visitors can encourage women to eat healthily and manage weight gain during pregnancy and monitor and achieve a healthy weight between and before subsequent pregnancies. Obesity in the mother can cause complications in and between pregnancies. Involving partners in conversations is important as paternal overweight is an indicator for childhood overweight.

During the 5 mandated visits, including the antenatal visit, health visitors can provide consistent, evidence-based messages on nutrition, oral health, managing weight gain and physical activity. Health visitors can use every opportunity to discuss the importance of a healthy weight and lifestyle with both parents, and signpost to relevant national resources such as One You, Start4Life and Change4Life, and to relevant local community activities.

During planned and opportunistic contacts, the health visitor can provide advice, support and guidance on nutrition, physical activity and provide consistent healthy weight messages. Breastfeeding is associated with a decreased risk of tooth decay. Supporting mothers to continue breastfeeding is an important part of this. Where women decide not to breastfeed, they should be supported in that decision. Mothers who are formula feeding should receive adequate information on how to safely make up a feed, preferably on a one-to-one basis, in the early postnatal period. They also require information on the types of formula milk available, with the objective of encouraging them to use a first milk until the baby is one year old. Health visitors can engage mothers in conversations about the concept of responsive feeding and how this can make for a more contented baby and easier parenting in the long term.

Health visitors can discuss the importance of Healthy Start, including the fruit, vegetable and milk vouchers and vitamin supplements for all children under the age of 5, with pregnant women, new mothers, fathers, partners and those planning a pregnancy to promote take-up in eligible groups.

Health visitors can provide opportunities for parents to discuss issues or concerns, advice on behaviours, attitudes and family practices around lifestyle, including healthy eating and physical activity (following the Chief Medical Officer’s guidance). Examples include encouraging families to eat and be active together and encouraging parents and carers to set a good example by the food choices and physical activity habits they make for themselves.

Health visitors monitor child weight where there is concern about growth through their contacts, clinics and as part of the 2 to 2 and a half year review, encouraging parents to monitor growth and development as per guidelines in the Personal Child Health Record (Red Book). This includes being alert to, and assessing for signs of, under or overweight (including as a possible sign of neglect and faltering growth) and working with families to support them in addressing the family and child’s needs. Where needs are identified, health visitors can signpost and refer to additional support, based on clinical assessment of need.

Community

Health visitors can build community capacity for healthy eating and physical activity, by establishing or linking to community groups. Physical activity examples include working with the community to facilitate active lifestyles such as safe active play, outdoor and leisure activities. Promoting healthy food examples include community-led initiatives such as support for families on low income on how to feed their child well on a low budget, for example fruit and vegetable co-operatives and cook and eat groups.

Health visitors can have a lead role in promoting healthy nutrition and physical activity for infants and young children through early years services, for example by leading the implementation and delivery of evidence-based programmes such as the UNICEF UK Baby Friendly Initiative and HENRY (Health, Exercise and Nutrition for the Really Young).

Health visitors can encourage parents to sign up for the Information Service for Parents, which offers a series of emails and text messages for parents covering pregnancy and children up to 4 years old. They promote uptake of Healthy Start vitamins and vouchers to parents who are eligible.

Population

Health visitors lead the Healthy Child Programme: Pregnancy and the first 5 years of life and provide leadership at a strategic level to contribute to the development and improvement of policies, pathways and strategies. This supports the delivery of high quality, evidence-based, consistent care for children and families for improving healthy weight and healthy nutrition.

Health visitors can influence local pathways and support the development of health policies, ensuring that early years services promote clear, consistent messages about healthy eating and the benefits of physical activity, including provision of healthy snacks and drinks and reducing tooth decay.

At a population level the National Child Measurement Programme provides a detailed picture of the prevalence of child obesity. This information is used locally to identify areas of need in children starting school and supports the development of targeted multi-agency interventions for pre-school years.

In August 2016, the government launched the first chapter of the Childhood Obesity Plan, setting out the approach to prevent and reduce childhood overweight and obesity, working with local communities, the food industry, schools and the NHS. Building on the first chapter of the childhood obesity plan, the new measures included within chapter 2 of the childhood obesity plan focus on:

improving the nutritional content of the food and drink children consume
strengthening the information available to parents about these products
changing the way that unhealthy food and sugary drinks are promoted

The plan calls for action in relation to enabling health and care professionals to raise the issue and support families to achieve and maintain a healthier weight.

Tackling obesity is complex and will require coordinated action and integration across multiple sectors including health, social care, planning, housing, transport and businesses. Health visiting teams form part of the whole system approach to tackling obesity by supporting children and their families to make healthier choices to reduce the risks of preventable ill-health.

Question 4

Using evidence to support delivery

Accepted Answer

A place-based, or community-centred, approach aims to develop local solutions that draw on all the assets and resources of an area, integrating services and building resilience in communities so that people can take control of their health and wellbeing, and have more influence on the factors that underpin good health.

The All Our Health framework brings together resources and evidence that will help to support evidence-based practice and service delivery, Making Every Contact Count and building on the specialist public health skills of health visitors.

Most health and care professionals focus on interventions which tend to be delivered on an individual basis, however health visitors and school nurses focus on individuals, families and communities’ approaches. It is critical that all professionals consider the importance of population health as an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.

Social prescribing complements such approaches enabling public health nurses and other health and care professionals to refer people to a range of local, non-clinical services. Health Visitors recognise that children and young people’s health is determined primarily by a range of social, economic and environmental factors, social prescribing seeks to address individuals needs in a holistic way, supporting them to take greater control of their own health.

Question 5

Measures of success or outcome

Accepted Answer

High quality data, analysis tools and resources are available for all public health professionals to identify the health of the local population. This contributes to the decision-making process for the commissioning of services and future plans to improve people’s health and reduce inequalities in their area including child and maternal health profiles, measures of access and service experience. Health visitors and wider stakeholders need to demonstrate the impact of improved outcomes. This can be achieved by using local measures.

Access

Measures include:

evidence of use of up to date, evidence-based, multi-agency infant feeding policies, setting out best practice in relation to breastfeeding support, introduction of solid foods and dietary guidelines in early years services that would reduce obesity and tooth decay
evidence of a local multi-agency 0 to 5 healthy weight pathway setting out best practice on assessment, identification and interventions for healthy weight for 0 to 5 via local commissioner and provider data

Effective delivery

Measures include:

evidence of implementation of infant feeding policies (UNICEF guidance and standards) and healthy weight pathways via local commissioner and provider data

Measuring impact

Measures include:

User experience

Measures include:

feedback from NHS Friends and Family Test and from health visitor service user experience questionnaire on satisfaction with breast-feeding

Question 6

Connection with other areas

Accepted Answer

The high impact area documents support delivery of the Healthy Child Programme and 0 to 5 agenda, and highlight the link with a number of other interconnecting policy areas such as the maternity transformation programme, childhood obesity, speech, language and communication, immunisations, troubled families, mental health, social mobility action plan and oral health as part of the Best Start in Life. The importance of effective outcomes relies on strong partnership working between all partners in health (primary and secondary), local authority including early years services, and voluntary sector services.

Best Start in Life has been identified as a priority as part of PHE’s 5-year strategy, which runs from 2020 to 2025 and is included in response to the Prevention Green Paper (Advancing our Health: prevention in the 2020s).

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy and Maternity Programme are currently developing and implementing infrastructure to improve access and timeliness of data with the aim of knowing where every child is and how well they are. This includes the development and implementation of a Digital Parent Child Health Record. This programme supports the ambitions and modernisation of the Healthy Child Programme.

Collaborative working

Approaches to improving outcomes through collaborative working include:

using the Public Health Outcomes Framework indicator reporting and benchmarking by PHE
local commissioning information sharing agreements in place across all agencies
integrated commissioning of services
early years services play a key role in identifying children who are overweight or at risk of obesity, supporting improved outcomes for children and families as part of the integrated planning, delivery, monitoring and reviewing approach
partnerships can use information from Joint Strategic Needs Assessment (including, health data, information about families, communities and the quality of local services and outcomes from integrated reviews) to identify need and respond to agreed joint priorities
data to inform Joint Strategic Needs Assessment on obesity in reception aged children, breastfeeding, dental decay in 5 year olds, hospital admissions due to tooth extractions (NHS Outcomes Framework indicator) nutrition and exercise to develop partnership healthy weight strategies with clear pathways for support for parents and young children at risk from obesity
demonstrating value for money and return on investment

Improvements

These include:

improved accessibility for vulnerable groups as health visitors access all families
integrated IT systems and information sharing across agencies
development and use of integrated pathways to include prevention and early intervention
systematic collection of user experience for example NHS Friends and Family Test, local authority led consultation exercises with parents and carers on local services to inform action
increased use of evidence-based interventions, for example, HENRY and links to other early years performance indicators
improved partnership working, for example maternity, school nursing and early years services
consistent information for parents and carers on obesity, nutrition, portion control and activity
identification of children who are overweight or obese or risk factors and indicators for obesity for example poor oral health
appropriate alignment to breastfeeding priority area
ensure local processes to enable smooth transfer of records during transition to school to ensure continuity of programmes
high coverage of Healthy Child Programme (0 to 5) and weight, height and BMI centile measurements at 2 to 2 and a half year review

Professional or partnership mobilisation

These include:

multi-agency training on risk factors and root causes of obesity and how they relate to other public health priorities for example tooth decay
multi-agency training for healthy weight, including nutrition and activity
effective delivery of universal prevention and early intervention programmes
improved understanding of data within the Joint Strategic Needs Assessment to inform the Joint Health and Wellbeing Strategy and at the local Health and Wellbeing Board to better support integrated working of health visiting services with existing local authority arrangements to provide a holistic, joined up and improved service for young children, parents and families
identification of skills and competencies to inform integrated working and skill mix
analysing data from the National Child Measurement Programme and the National Dental Epidemiology Programme to target delivery of services
closer links with early years services, education settings, school nursing and oral health services
role of health visitors in supervising peer mentor programmes