Research and analysis

PHE centres: Midlands

Updated 15 February 2021

Coventry

The local authority took an iterative whole-systems approach to weight management to increase engagement in behaviour change for children with a focus on deprived schools. Coventry chose a whole-systems approach as they recognised that individual services were not enough within their population. Their objective was to reduce childhood obesity.

At the time this research took place Coventry was a metropolitan area with an estimated population of around 352,900 people (Coventry Insights, 2016).

Local approach

Coventry had unsuccessfully applied to be part of the first cohort of areas of local authorities involved in the Leeds Met Whole Systems Approach project. Coventry emphasised how the public health annual report clearly articulated the unstructured nature of the local obesogenic system and the importance of a whole-system approach.

Before 2010, there was no emphasis on a children’s weight management provision. An investment was made, however, in a new service: Be Active Be Healthy (BABH) which then provided a family weight management provision (FWMP) that was the focus at the time this research took place. Working predominantly within primary schools (with deprived schools targeted in particular), the service worked with an estimated 1000 individuals a year, a small proportion in terms of National Child Measurement Programme (NCMP) numbers.

The FWMP consisted of a 10-week programme of 2-hour sessions, where at least one parent had to attend along with their child. Follow up phone calls were made at 3 months, 6 months and 1 year to signpost towards universal offers such as leisure centres, or to offer a supportive conversation. The follow-ups also facilitated information gathering in order to measure the impact of the scheme. This service was developed with Coventry University and work was underway to ensure the programme was grounded in evidence and thus used best practice to support behaviour change.

Coventry did not have a formal weight management strategy, however, the 2016 Director of public health (DPH) report focused on family weight management and advocated for a whole-systems approach. As a result of the report, an alliance was created in 2015 to 2016, with the intention of utilising the finished report. The alliance brought a number of stakeholders together to discuss what could be done and which areas to focus on. These conversations lead to the development of 2 work areas, early years and within schools. In line with the DPH report, treatment for obesity and overweight was perceived as the last stage of the pathway with other interventions seen to come first. The alliance was meeting quarterly and had met 6 times at the time this research took place.

Coventry had strong partnerships with other local authorities in order to share what has been learned. For example, Coventry was moving towards creating an integrated family health service provision and meetings were taking place to collaborate with other councils about how best to approach this. There was strong political support in the political cabinet, as well as at council level, and an awareness that childhood obesity linked in with many other council strategies, such as green spaces and the sports strategy.

Collaborative strategies

Collaborating with parks and sports colleagues, a programme called Kids Run Free was set up involving 2 monthly park runs.

Community-led walks around local parks called a ‘Magic Mile’. The idea was that families move around their local park in any way – walking, running, cycling, scooting and so on. These were held monthly and were run by local activists and volunteers.

There had been a significant investment in activity routes and markers in parks around the city under the project name Coventry on the Move in Parks.

The council’s sports strategy referenced ‘health’ in general with a range of projects – such as school games – coming under this.

Coventry was bidding and had been shortlisted for the City of Culture 2021. There was a strand of work within this relating to child health and healthy weight.

Coventry had been working in partnership with Sport England and their cabinet member for public health (who was also the physical activity champion for the West Midlands Combined Authority (WMCA)) on the development of the WMCA’s physical activity strategy (called West Midlands on the move). This strategy was launched in Coventry 2 weeks before this research took place. There was commitment to follow this up and develop a physical activity strategy for Coventry.

Overall, there was a political commitment with cabinets being held to discuss commitment details and practicalities. Childhood obesity was influencing planning and there was an aim for the planning team to look at a supplementary planning document and licensing arrangements for hot food takeaways. Further, since 2011 Coventry had been considering the health implications of wider planning applications.

Active travel

Coventry also had an emphasis on active travel.

The council provided the Bikeability cycle training programme to schools for a number of years – this scheme was part funded by the Department for Transport but families needed to provide a financial contribution. Coventry had further invested in this to make it more widely available to schools and families in greater deprivation.

There were other programmes within schools surrounding this, for example, Living Streets ran the WOW Walk to School programme in a number of schools. The collaboration enabled Living Streets to target schools in greater deprivation and, or those with higher levels of overweight and obesity levels.

Colleagues working on improving air quality developed an active travel campaign, combined with Warwickshire, called Choose how you move.

Family weight management universal services and initiatives were predominantly delivered within schools. A school network existed which was promoted by the school nurses, similar to the old healthy schools programme. A lot of engagement existed within the childhood obesity agenda, ranging from free school meals, healthy tuck, and the food for life programme, and ensuring good nutritional standards at breakfast clubs. As such, weight management tiers in Coventry were linked.

Deprivation

Coventry had a strong focus on health inequalities across the city. Coventry was a Marmot city and this was a focus of the Health and Wellbeing Board. Deprivation is an overarching thread in childhood obesity, and this continued to push through their commissioning from 2018 with an aim to spread proportionate universalism across services.

National Child Measurement Programme

The school nurse team carried out the weighing and measuring and routine feedback was sent back to the schools from the public health team. GPs, however, did not receive feedback. The school nurse team were linked with the BABH team, and in some schools, the BABH team spoke with parents offering support after school on measuring days. The BABH team operated in schools targeted from the NCMP data. There were plans for the BABH team and the school nursing team to join the integrated family health service with an aim to positively impact working relationships.

A school nurse was the NCMP lead and also the point of contact for the public health team in relation to the NCMP. Letters were sent to parents of overweight and very overweight children with details of the BABH team and the school nurse team contacted the parents to offer support. All the NCMP data was shared with the BABH team.

Coventry found the NCMP data useful for providing evidence that supported its place in political priorities. Coventry faced some criticism over the costs of obtaining the NCMP data but found that the data was useful in providing a focus, highlighting the problem and producing evidence which supports its place in political priorities.

Outcome

At the time this research took place it was too early to say whether this approach would reduce childhood obesity.

Advice to other local authorities

It’s vital that relationships are built, and partners gain an understanding of the issues.

Derbyshire

The local authority took a preventative, life-course approach to preventing childhood obesity with emphasis on early identification, intervention and behaviour change for children and families. Their objective was to reduce childhood obesity.

At the time this research took place, the population of Derbyshire was 769,686 (UK census, 2011). Derbyshire was renowned for being a hugely diverse county with the town and city nestled in the countryside with industry and leisure working hand in hand.

Local approach

At the time this research took place public health took a preventative, life-course approach to enable children and young people to adopt healthy lifestyles in an attempt to prevent weight being an issue. The emphasis was on early identification, intervention and behaviour change to support children, young people and families.

Derbyshire County Council’s public health department did not commission a referral programme specifically for obese children. However, some districts and borough councils offered lifestyle programmes through their Leisure Services provision, as did some of the School Sports Partnerships linked to schools, such as the Change4Life clubs.

Below is a chronological list of interventions that were offered in Derbyshire at the time that this research took place.

1. Pregnancy and early years lifestyle programme (pilot)

Staveley Healthy Living Centre and Queen’s Park Sports Centre provided a 9 month offer of physical activity from pregnancy into early years and toddlers.

2. Peer breastfeeding support

Universal coverage across Derbyshire County provided one-to-one support for mothers who wished to breastfeed from day 2. Evidence suggested that this support increased exclusive breastfeeding and sustainment.

3. Walking for Health

This included buggy walking and teddy walking.

4. Core offer of public health nursing (0 to 5)

The offer, which contributed to school readiness, included:

• preparation for parenthood
• breastfeeding promotion
• healthy lifestyles
• health reviews at 10 days, 6 to 8 weeks, under 12 months and 2.5 years that covered environmental factors, child development, emotional and physical well-being and parent concerns – the review also covered lifestyle and healthy weight, as appropriate to individual family needs specific to the 2.5 (nationally reported) measurements.
• early prevention and intervention in partnership with Derbyshire County Council children’s services

5. HENRY (Health, Exercise and Nutrition for the Really Young)

HENRY was an 8-week course for parents and carers of children under 5 years, which explored skills and ideas to support a healthy lifestyle and emotional wellbeing.

6. Breakfast clubs

This was a funded collaboration between public health and children’s services, which aimed to improve pupil health, attainment, attendance and behaviour. It targeted selected primary schools in areas of high deprivation. Public health helped to ensure that the breakfast offer was of good quality nutritionally without undermining the healthy school lunch requirements.

7. Holiday programmes (Holiday Hunger)

The holiday programmes aimed to provide food, nurturing, caring and support to the most vulnerable, by bringing together different partner organisations that typically supported vulnerable children and were committed to coordinating and facilitating a range of holiday provision within a given community. The offer would extend to:

• meals – either breakfast, packed lunch or both
• social enrichment – such as games, reading, outdoor pursuits and other activities
• opportunities to socialise with similar aged children
• opportunities to experience new pursuits and learn new skills
• a safe and supportive environment

8. Five60

This 10-week personal, social, health and economic programme was aimed at school years 3, 4 and 5, to try to address the obesity prevalence increase between reception and year 6 as measured by the NCMP data.

The core elements included:

• physical activity
• healthy eating
• hydration
• confidence building
• behaviour change

This was offered to all primary schools via district and borough councils. It was a 10-week programme of one-hour sessions offering brief interventions on physical activity and nutrition and behaviour change. It included the travel smart programme which encouraged walking and cycling and also covered road safety. It ran during school time and was well embedded. The programme launched in 2009 to 2010.

9. Derbyshire Food for Life (FFL)

FFL transformed the whole school food culture by supporting schools to achieve the FFL school award, and achieve a county-wide FFL Catering Mark to provide healthy school meals, great lunchtimes and food education that had a positive impact on both pupils and the wider community.

10. Derbyshire My School Lunch

More information can be found on the My School lunch website.

11. Forest school

Forest school delivered training and support to 16 staff members annually as Level 3 Forest School Leaders to improve the mental and physical health and wellbeing for Derbyshire Young People.

12. Core offer of public health nursing (5 to 19)

This included:

• school entry health review
• year 6 health review including NCMP, hearing and vision screening
• year 8 health promotion
• TeenScreen, including smoking review, health and lifestyle
• targeted support to children who were vulnerable with health needs, particularly those who were absent from school more than 15% of the time

13. Live Life Better Derbyshire (16 and over)

Live Life Better Derbyshire offered support to:

• lose weight
• get active
• improve wellbeing

14. Heart of Derbyshire

This was an award scheme to encourage local food caterers to include healthier meal options on their menus.

15. Active Derbyshire

This web-based site provided information and local links to help families get active.

16. Public health locality fund

Funded projects that met the locality plan health priorities.

17. Planning and hot food takeaways

This was a pilot in Chesterfield working across public health and Chesterfield Borough Council planning and environmental services to map hot food takeaways and explore a case for restricting takeaways in close proximity to schools through the planning process.

18. National links

National links that were particularly useful for Derbyshire to support healthy eating and physical activity behaviour change included:

• Change4Life
• The Eatwell Guide
• the NCMP data
• NHS Choices
• Food a Fact of Life
• Children’s Food trust (charity)
• Learning Through Landscapes
• Play England

19. Healthy School Communities Award

This was commissioned via the school nurse service. They identified a family of schools (a secondary school and its feeders) then undertook a whole-school assessment of its health promotion offer and assessed if it was a healthy workplace for staff. They then linked them with other interventions including FFL, as part of the toolbox available to them. This was one of the reasons why the public health team tried to strengthen the relationship between the school nurse team and the school sports partnership. The school nurse team would get the list of services from the county to add to the toolbox and then relied on information given to them by other providers or commissioners, but when the individual boroughs and districts commissioned their own projects, the school nurse team might not have known what was available. The school sports partnership was a good source of information on the wider offer as well as a service provider in its own right.

Outcome

At the time this research took place it was too early to say whether this approach would reduce childhood obesity.

Advice to other local authorities

Using Chesterfield as an example, they had a high level of childhood obesity overall but used the data to drill down to smaller areas. They also identified what the local issues were, identified what the causes were, and identified what was already on offer (to avoid duplication) as well as worked out who their potential partners were (and whether or not new partnerships needed to be formed or whether existing ones could be used) for their success.

Nottinghamshire

The local authority took an iterative whole-systems approach to tackling childhood obesity with a focus on increasing family engagement, collaborating with planning, transport and environmental health.

The first NCMP data for Nottinghamshire showed quite high levels of childhood obesity and as a result of this, the local leadership focused on it as an issue.

The approach was derived iteratively, based on evidence, evaluation and consultation with, and feedback from, the community. Their objective was to reduce childhood obesity.

At the time this research took place (2015), Nottinghamshire was a metropolitan area and had an estimated population of around 785,800 people.

Local approach

Nottinghamshire supported a number of initiatives to prevent and manage childhood obesity.

The Health and Wellbeing Strategy had a large focus on obesity. The framework looked at all determinants of obesity and had a whole-systems approach, it was written by the acting DPH.

An excess weight strategy group existed with representatives from all district councils and relevant service areas from the county council.

Progressive work with spatial planning was done at a district level on where and how houses were built. From this, there was a spatial planning protocol which set out the relationship between planning, health and social care in a document. There was an awareness of the cross-cutting benefits of this approach, such as across mental health and a poster was presented at the Public Health England (PHE) conference in relation to this.

Nottinghamshire collaborated with transport planning to help enable sustainable transport, particularly cycling. They worked with district environmental health, who were working with food outlets to encourage them to provide a wider range of healthy options.

Each district was doing its own things, for example, Rushcliffe’s health partnership was particularly strong and had been maintained over the years.

A single provider was commissioned for the all-ages prevention and weight management service and they were continually defining their Tier 1 offers within schools (healthy eating and, or, physical activity), children’s centres and health walks. At Tier 2, Nottinghamshire had a children and families weight management service and an adult service. At Tier 3, which was mainly for adults, there was a weight management programme with higher uptake than the Tier 2 offer. Tier 3 was intended to be holistic and it included mental wellbeing support from bariatric nurses.

In relation to the children and family weight management services, the need was there but not the demand, so the county council asked the provider to evaluate their marketing and check that the offer was attractive as uptake was not as expected. They were using the PHE guidance to support this.

Deprivation

The DPH of Nottinghamshire was particularly passionate about deprivation and proportionate universalism. The children and family weight management services ensured areas with greater need had higher targets and the service provider was expected to increase the support for these areas. There was an understanding that the service needed to be available everywhere, that there was high demand from areas with less need, and that areas with greatest need were the most difficult to engage. On the adult side, they agreed that the service provider could subcontract to commercial providers to release capacity, for example, WW (Weight Watchers).

National Child Measurement Programme

The NCMP was part of the 0 to 19 contract that Nottinghamshire Healthcare Trust won (the NHS trust that provided all community care in the area). A healthy families programme was utilised with dedicated staff that delivered the NCMP. Fingertips data presented that at county level, Nottinghamshire had one of the lowest uptake rates at year 6. In the year 2015 to 2016, Nottinghamshire started work to try to improve this, proactively talking to schools, head teachers and comparative areas with higher rates to gather intelligence. There was a feeling that some parents did not believe in the NCMP, therefore, Nottinghamshire explored how to address this and what areas they should target. Analysts formulated a list of schools with the lowest participation rates, cross tabulated it with the prevalence data and then worked with the top schools to encourage better use of the NCMP. Findings were shared with the NCMP team and the children and family weight management services.

The School Health Hub was formed in 2016 as a way of interacting with schools on all health issues for children and young people and for brokering with academia. There was a lead for obesity within the team, however, all health areas in the geographical area were covered. Part of the role was to link schools and through them, parents with the NCMP. This role helped push Tier 1 services into academia and improved the relationship between the weight management service provider and the NCMP. Further to this, relationships were built with schools and assistance was provided to help them to identify what they needed and how they could take a holistic approach. This way they could not only tackle obesity, but also build resilience within the same system, for example by looking at the connection between nutrition, physical activity and body image.

Furthermore, there was a named lead for NCMP within the 0 to 19 service who connected with the local authority public health team. Training was completed collaboratively between the public health team and the NCMP team in order to place the programme in context. Quality checking visits were conducted, where messages were monitored to ensure consistency, in line with policy and the quality of the service delivery. These checks also identified where linkages could be improved to increase uptake. To further increase uptake, the opt out options on the NCMP letter were changed to make it more difficult to opt out of the programme. Feedback from NCMP was routinely given to schools, but at the time this research took place, they were unsure if it was also given to GPs.

Outcome

At the time this research took place it was too early to say whether this approach would reduce childhood obesity.

Advice to other local authorities

Nottinghamshire highlighted the importance of collective working.

Shropshire

The local authority took a whole-systems approach with a further focus on integrating weight management services into schools through use of the school nurse team. Their objective was to reduce childhood obesity.

Shropshire chose their approach after exploring data from a range of sources and highlighting the main issues. Childhood obesity was seen as an issue requiring further work and resources.

Shropshire also focused on the link between mental health and physical health which resulted from consultations on the child and young people strategy. Attention was drawn to the fact that the strategy failed to emphasise happiness and wellbeing.

At the time this research took place, the 2011 consensus showed a population of 306,100 living in Shropshire. A greater proportion of the population lived in rural areas than in urban areas.

Local approach

Shropshire implemented several strategies and initiatives.

The Eat Better Move More programme, aimed at pre-school children, included nurseries and childminders. This was an accredited training scheme to encourage children to eat healthily and increase activity.

The HENRY course was run at baseline and provided a subtle way of relaying health messages to parents. A proportion of the messaging focused on portion control, as Shropshire found that parents were often getting their children to eat healthy food, but with adult portions. The DPH was a governor of Alder Hey Hospital and his work underlined portion control as a large issue, alongside oral health.

The Schools Sports Partnership ran a programme targeting physical activity through increasing the variety of sports on offer. Events featured a local olympic archer, and targeted specific schools with low levels of physical activity to involve as many children and young people as possible. This programme was well received.

Shropshire ran targeted activities across certain towns and villages, where they worked with and supported the local community to come up with its own solutions to encourage people to eat more healthily and increase physical activity. They were working across the age spectrum – initiatives included a less structured park run event and encouragement for young people to take up swimming.

Collaboration with local charities, particularly in aid of the local hospice, included midnight walks, colour runs, my marathon my way.

A network of young health champions was created. They acted as spokespeople at service design consultations and more proactive activities such as a diabetes awareness campaign. Shropshire believed that it was vital for this work to be led by children and young people, rather than by public health. The young people chose the materials and the mechanism for delivering the campaign and public health provided guidance and advice.

Linked to the young health champions was work on sex, relationships education and general health. Shropshire acknowledged the link between diet, self-esteem and mental health and thus provided a range of programmes targeting these.

Shropshire implemented active travel but faced restrictions in rural areas. In market towns, it was possible to create park rides and cycle lanes, whereas they were limited by scale within rural areas.

Deprivation

Deprivation was a focus within Shropshire. London and Shropshire had similar levels of deprivation, however, in terms of the Healthy Lives table, London was first, and Shropshire was in the 30s. Shropshire, however, was much less populated per square kilometre and this created restrictions to services relating to fewer people more spread out across a rural environment. This created challenges in centralising services.

National Child Measurement Programme

Delivery of the NCMP was supported locally by a multi-agency working group comprising representatives from Shropshire Community Health NHS Trust (SCHT) and Shropshire Council (children’s centre services, data acquisition and management team, and public health). This group met once every term and was chaired by public health. Letters, which signposted parents to the children’s weight management service and the Fit Families programme, were sent to parents of both under and overweight children.

The Fit Families programme was run by school nurses and provided concentrated support over a few weeks allowing a period of child monitoring to evaluate the impact of any changes made. The services offered were flexible and could be tailored for the family by the school nurse. SCHT School Nursing Service provided a first line advice service linked to the parents’ feedback letters and proactively contacted parents of children who were identified as being very overweight. This provided a referral route into the school nurse-led structured weight management service (Fit Families).

Schools received NCMP feedback, however, GPs received a degree of data through access to the local fingertip tools. Collaborative work was being conducted with the clinical commissioning group on how to localise the data in a way that could allow them to work differently. Shropshire had a childhood obesity lead in the school nurse team, but this was restructured to a 0 to 19 public health nursing service due to the realisation that health visitors may have had better access to primary school children.

In relation to weight management tiers, they were not well linked. Links between Tiers 1 and 2 were more straightforward. Tier 1 for example had advice available online and Tier 2 was delivered in GP surgeries and by the school nurse team, who could signpost back to Tier 1 information. The Tier 2 Fit Families children and families weight management service supported families with children who had a body-mass index (BMI) centile equal to or above the 98th centile. This school nurse led service provided behavioural change support to enable families to achieve and maintain a healthier weight. In the absence of a multi-disciplinary Tier 3 service however, over half of the children and young people formally entered into the Fit Family’s programme had a BMI equal to or above the 99.6th centile at baseline. The collaborative and innovative nature of the NCMP delivery model in Shropshire, alongside the expertise and experience of its school nursing team, enabled those families identified through the NCMP to receive valuable and trusted help – in the form of first-line telephone support and access to local, structured weight-management support.

Outcome

At the time this research took place it was too early to say if this approach would help reduce childhood obesity in the area.

Further work

At the time this research took place it was believed that some services would have to be suspended following the end of the public health grant in 2019. It was perceived that this would increase the focus on mandated services. If financial support was no longer provided for mandated items, local government would have a right to question why they should provide them.

Advice to other local authorities

Shropshire Council said:

Ensure the data is collected and then look hard at what it says about the overall population of children but also subsets, and that enables you to create a programme suitable for their local community. Different populations within the community will have different barriers and challenges and might have different levers that could affect it. For example, never underestimate the importance of an enthusiastic head teacher or local community group.