Research and analysis

PHE centres: North of England

Updated 15 February 2021

Cheshire East

The local authority developed an integrated lifestyle system in managing childhood obesity, with a focus on whole-family engagement in weight management. Their objective was to reduce childhood obesity.

At the time of research, Cheshire East’s population was 370,700. It was the third-largest unitary authority in the North West, after Manchester and Liverpool.

Local approach

One You Cheshire East was an integrated lifestyle system and a universal service. It was anticipated at the time of this research that when take up increased it would become a targeted, place-based system with limits on the number of people from each borough who could access the services. One You Cheshire East provided a single point of access for a number of lifestyle services, including smoking, alcohol and healthy eating. This programme was predominately aimed at adults.

People who made contact were screened and then directed to services as appropriate. Most services were offered by former council leisure services that became independent, although other providers delivered the smoking and alcohol services. It contained the Family Weight Management Services (FWMS), Let’s get Movin’, a 12-week programme for the whole family.

The National Child Measurement Programme (NCMP) letters sent to parents provided details of the FWMS and a school nurse contact. The FWMS involved both parents and children, covering nutrition, cookery and discussions or activities around physical activities. The FWMS are a Tier 2 service, but there was no linkage with any other tier. Anyone with a body-mass index (BMI) of over 40 was seen as a Clinical Commissioning Group issue. There was awareness that more linkage would be useful. However, Cheshire East was restricted due to resources.

The health improvement team were running an initiative with schools (staff, parents, children) about what makes a healthy lunchbox. This was targeted at schools of greatest need, identified through the Joint Strategic Needs Assessment, which was viewed as separate from the NCMP.

The initial idea for the programme came from the public health (PH) team and got cabinet approval.

The PH team were involved in intelligence gathering and would send a questionnaire before the New Year to schools to gather information on what they were doing regarding childhood obesity.

Cheshire East was also planning a new initiative around childhood obesity champions but not much information was available at the time this research took place. It was thought that the borough would be split into 8 areas and each would have a childhood obesity champion.

National Child Measurement Programme

The NCMP was run by Wirral Community NHS Trust and the school nurses, although assistants conducted the weighing and measuring and sent the result letters to parents. These contained information about the FWMS and a school nurse contact. It was then the families who decided whether to take up the offer. Schools received feedback on the NCMP data. Although this data was not shared with general practitioners (GPs), GPs could refer children to the FWMS.

Cheshire East were not aware of any specific linkage roles between NCMP and the rest of the system.

Outcome

At the time this research took place it was too early to say whether this approach would reduce childhood obesity. Cheshire East’s NCMP figures placed them in the top quintile in the country but the One You programme had not been running long enough for it to have realistically been able to contribute to that trend. There was a feeling that the trend may relate to the affluence of the area, although it did also have pockets of deprivation.

Further work

Work continued via One You Cheshire East, as did the planning for the new Childhood Obesity Champions project.

Find out more about family life and parenting at Cheshire East Council.

North Yorkshire

North Yorkshire implemented a whole-systems approach with the Food For Life Programme, supporting schools to take a whole-school approach. Their objective was to reduce the prevalence of overweight and obesity across the population.

North Yorkshire had an estimated population of approximately 604,900 in mid-2016. Harrogate had around 75,070 residents and Scarborough around 52,100.

Childhood obesity was a priority for North Yorkshire County Council. Over 21% of 4 to 5 year olds, over 30% of 10 to 11 year olds and over 60% of adults in North Yorkshire were living with excess weight. This rate of excess weight was of concern because of its effects on physical and mental health and reduced healthy life expectancy of those affected. Although the levels of excess weight for children in North Yorkshire were below the national average, there were still 2,716 4 to 5 year olds and 3,822 10 to 11 year olds who needed support to achieve and maintain a healthy weight. Much more needed to be done to enable people to work towards an optimal weight and to turn the tide on the prevalence of obesity across the county.

Local approach

At the time this research took place, North Yorkshire had recently launched its obesity strategy ‘Healthy Weight, Healthy Lives: Tackling overweight and obesity in North Yorkshire 2016 to 2026’. This included a priority around ‘supporting children’s healthy growth and healthy weight’. Below are a series of actions that the county was trying to achieve.

Healthy Choices

Healthy Choices was a bespoke family service aimed at 5 to 19 year olds who were above a healthy weight, delivered by a team of healthy lifestyle advisors. The team worked with families over 12 weeks to make positive, realistic and achievable changes to their lifestyle, that were suitable to their individual circumstances. Each family was also offered follow-up visits at 6 and 12 months for further support.

MoreLife

The MoreLife residential weight management camp supported young people (age 8 to 17 with a BMI centile of above 99.6 for age and or gender) to change lifestyle habits through re-education of healthy eating, increasing physical activity levels and understanding the personality traits and triggers that influenced unhealthy lifestyle behaviours.

Food for Life

The Food for Life Programme in North Yorkshire was supporting schools to take a whole-school approach that saw them growing their own food, organising trips to farms, as well as providing cooking and growing clubs for pupils and their families.

HENRY

Health Visitors and Assistant Practitioners from the 0 to 5 Healthy Child Service had all received core training in the HENRY (Health, Exercise, Nutrition for the Really Young) approach during 2017. In addition to the core HENRY training, 14 staff had received advanced HENRY training which allowed them to offer a one-to-one targeted intervention with families of babies and young children over the 91st centile.

Healthy Movers

The Youth Sport Trust delivered Healthy Movers within Scarborough as a pilot scheme. Healthy Movers is an initiative that supported early year’s settings and parents of 2 to 5 year olds to use training and resources in the childcare setting and at home.

The aim of Healthy Movers was to increase the number of children aged 2 to 5 years achieving the recommendations for physical activity (180 minutes a day).

Eleven early years settings in Scarborough attended the Healthy Movers training and obtained teaching resources and home packs to engage children’s families with their physical development journey.

National Child Measurement Programme

Under the NCMP, a Make Every Contact Count aspect was included and ‘It’s more than just a measurement’ strapline was adopted for the service. For example, it was seen as an opportunity to offer brief advice to children, and resources from Change4Life and My Healthy Year were promoted in schools. From the NCMP, the children identified as overweight or obese were signposted to and informed about the Tier 2 children’s weight management service (Healthy Choices). Schools, parents, professionals and children themselves could all refer children into the programme. Routine feedback from the NCMP was given to schools and parents, but not to GPs. There was a school nurse who had a lead role on the NCMP and children’s obesity.

The tiers for weight management were linked. For example, the Healthy Choices programme referred patients into the MoreLife residential weight management programme, and then the expectation was that the child would return to the Healthy Choices programme for further 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

A healthy weight pathways booklet for children and young people was being developed to illustrate the different tiers of weight management and how they are linked. It was to be aimed at professionals to ensure that evidence-based, consistent, seamless support and care was offered by partners working to deliver the 0 to 19 Healthy Child Programme.

St Helens

St Helens developed a whole-schools approach to weight management, emphasising collaboration with partners and business to ensure healthy messages are promoted within schools. The objective was to reduce levels of childhood obesity.

St Helens is a large town in Merseyside and was the largest settlement of the Metropolitan Borough of St Helens, making up part of the wider Liverpool and Birkenhead Metropolitan Area. The entire borough had a population of 177,188 (Office of National Statistics, 2014).

Local approach

In 2014, the PH team engaged with stakeholders and partners, such as council departments, health and public sector to put together a healthy weight strategy which had 3 themes:

• people
• places
• policies

Methods of tackling excess weight throughout all council departments was embedded using unique approaches. For example, the environmental health team promoted the Chip Fryer Award.

The PH team began commissioning further projects. Six outdoor gyms were installed in the largest parks in the areas of high deprivation where NCMP data showed there were high levels of childhood obesity. A permanent post was created in the catering department for an executive chief to overhaul school menus and provide a nutritionally balanced offer that was attractive and met national standards. For schools that accessed their meal provision via the council, there was staff training on portion size, food groups and messaging around healthy eating.

Money was invested in local healthy living services at a universal level and the Healthy Weight Service for adults was decommissioned to focus on this. At the time this research took place, they were targeting schools with high levels of obesity and developing a whole-school approach award, based around physical activity and nutrition. This was running as a pilot with 10 schools in 2017. Initially the local authority had been waiting for guidance following the government’s Childhood Obesity Action Plan, which was expected to create a new healthy rating scheme for primary schools. However, the local authority has gone ahead with their own version. The pilot hoped to increase collaboration by getting the same healthy messages into schools as those that were promoted outside school.

To get the Chip Fryer award, schools needed to embed these in the curriculum and sign up to the council’s food and activity policy, which included the Tasty Tuck award (healthy tuck shops). A Healthy Early Years (HEYs) status award had also been developed for early years settings, based on active play and messages on nutrition. In the previous 12 to 18 months before this research took place, the HEYs award had been adapted for childminders who as a group were not well supported or monitored. There had been excellent engagement with over 50% uptake of local childminders. The award took a personal approach where the lead met the childminder in their setting and went through a one-to-one assessment. Part of HEYs was also about getting healthy messages taken back into the home, so some HEYs teddy bears were distributed to providers – children took them home and would take a picture of the bear doing something healthy, which could be spread through social media.

St Helens were partnering with the local sports development team and a local Rugby League team (Saints), which gave a small number of group sessions to local children. In October 2017 every primary school child attended an information day at the stadium for a broad range of public health messages, from fire safety to nutrition and physical activity. This was supported by players from the team.

The childhood obesity strategy ended the same year this research took place and was being refreshed. A whole-borough approach was taken, including businesses and creating community champions. As part of this, a panel event was held: ‘The F Word’, where representatives from the local Clinical Commissioning Group (CCG), NHS Trust, commercial centre, college and the PH team answered questions from an audience of both the public and invited local business people. About 35 to 40 people attended, but not as many businesses as hoped, highlighting the challenge of getting them to engage.

The council signed a healthy weight declaration in 2016 and as a result it wanted the town to sign up to healthy weight. Personal responsibility was deliberatively targeted on a community level to create momentum from the population rather than the council solely driving this.

Work was ongoing to integrate the local care system. The large trust provider (NHS), council, CCG, police and fire collaborated and pooled resources to form a Staff Health and Wellbeing Board tasked with making work settings more conducive to health (70% of employees working for these organisations in the area were from St Helens).

The Healthy Living Team was also doing work on breastfeeding where midwives offered a 7-day service to provide breastfeeding support and engage in wards early on. This had increased initiation rates. A poster campaign was also run to improve attitudes in teens regarding the choice to breastfeed (with BFI recognition). Services offered were universal and specialist. The Healthy Living Team ran group universal sessions for different age groups (which could be flexible if families had children across age groups). There were also health trainers and advisers who worked one-to-one with adults. They then extended this to parents who needed support and created a family pathway to this support. Moreover, a specialist Family Weight Management Programme (FWMP) was available and barriers had been removed for participating and attending, as specialist advisers went into people’s homes to deliver advice.

In terms of who was driving the childhood obesity agenda, public health was the main lead to ensure the childhood obesity strategy was a focus. There was a Healthy Lifestyles Forum which was chaired by the Director of public health and included managers from across the council, which acted as a governance or information sharing group. The forum reported to the Peoples’ Board (which replaced the Health and Wellbeing Board). Management of the Healthy Weight forum was being refreshed, along with the strategy which was hoped would result in a wider circle of partners joining.

Essentially there were a range of things in place in schools and the community and this approach was being refined based on their learning to date. It was hoped that the schools pilot would provide an evidence base to help other schools learn and take up the award.

National Child Measurement Programme

The NCMP was run by the 0 to 19 contract provider, which had very recently changed when this research took place. This had created some disruption. The NCMP was led by the school nurses team. Health screeners within the team carried out the weighing and measuring. The Public Health England (PHE) template letter was sent out, but it had been made more parent friendly.

Working as a partnership was also visible here as the Healthy Living Team were involved, providing support on how to increase screening and on how to engage people after they had been screened. Nutritional support and physical activity support were available after screening regardless of BMI. However, the parent or carer of every child that was identified as having excess weight received a phone call from the school nurse team before the NCMP letter was sent to create a softer landing for the letter. It also gave parents a chance to hear more about the NCMP, how it worked and what it was for, as well as what it had found regarding their child. They could ask questions immediately, talk through the findings and receive advice and offers of services. This started the year before this research took place, and although evaluation information was requested from the service provider, the change in provider meant this was not received. Anecdotal evidence was that it was the first year the PH team did not receive any complaints about the letter.

Further parental involvement in the screening process was also piloted, whereby parents could engage with a professional before the measuring was done or they could be there as their child was measured. Health conscious parents were found to primarily attend with the concern that their (healthy weight) child was underweight, and they were tempted to increase feeding. This meant that advice could be offered to counter this.

In the past the NCMP had been an epidemiological exercise rather than a meaningful one. However, it was hoped that this would change at the time of this research taking place with a consistent provider for the next few years. Nevertheless, the NCMP did not seem to generate referrals to the FWMP. Improvements were being attempted, by giving children a fun card game at the point of measurement, which included messages about healthy eating and physical activity. They were also rolling out giving out stickers to year R, where they promised to:

• eat more vegetables
• eat more fruit
• be more active

Feedback from the NCMP did not go back to the schools nor GPs and there was not a school nurse lead of childhood obesity, but this could be considered in the future.

The NCMP did not line with the FWMP. However, the FWMP provider was going to be a part of the whole-schools pilot. It was hoped that having the FWMP provider as a partner in the whole-schools programme would increase its reach and that the provider would lead on working with schools with the highest levels of childhood obesity.

Other initiatives included:

• a PHE North West forum which could be used more effectively for sharing ideas and challenges
• for active travel, a post was commissioned in the transport planning team to increase cycling – although there were initial recruitment issues, this was embedded as partners received staff training and were given access to the cycling hub
• a healthy walks programme in the Healthy Living team
• a post attempting to engage with businesses and the unemployed to encourage them to use cycling as a mode of transport

Deprivation

Deprivation was a focus as St Helens had high levels of deprivation and some rather extreme differences between the least and most deprived areas. NCMP data by ward demonstrated that typically high deprivation meant high rates of excess weight, which had led to resources being targeted in those areas. In the last 10 years prior to this research taking place, there had been a focus on cardiovascular disease and the area had some of the fastest improving rates in the country at the time of this interview. This approach was hoped to be repeated with obesity. The intention was for a whole-systems approach across the borough, together with targeted approaches in areas of high need as the culture needed to change across the borough.

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.

Their advice to others starting a similar project is to take the time to engage as many stakeholders as possible to gain commitment. St Helens would recommend making a locally adapted declaration that businesses and organisations can commit to, with actions to address excess weight.

Further work

At the time this research took place St Helens had not experienced significant cuts to its weight management services and it was hoped that the council signing up to the healthy weight declaration would ensure resources for the next few years.

Wakefield

Wakefield introduced an iterative practice evolution to increase parental engagement in behaviour change, with the aim of improving rates of childhood obesity.

When the first NCMP data came out, Wakefield showed quite high levels of childhood obesity, and as a result the local leadership focused on it as an issue. This project started in 2007, and at the time this research took place it was ongoing.

Wakefield had a population of around 333,759 people. It’s a metropolitan area that included Wakefield city, 5 major towns, a number of smaller towns and areas of rurality.

Local approach

A joint public health unit was set up across the council, adults and children social care and public health. It was challenged to put together a programme to tackle childhood obesity and was provided with £2 million funding. Prior to completing its design, Change4Life launched, so they decided to keep the branding and messaging and make its programme a local Change4Life, in order to benefit from national campaign work. When the programme was evaluated, there was an identifiable trend for recognising the public health messages that had been promoted.

Following this, 3 areas with the highest levels of childhood obesity were identified and targeted. Workshops were carried out with the local community focused on the barriers to accessing healthy food options and on increasing physical activity. A number of Change4Life roadshows were run in familiar and trusted places, and sufficient time was given for the public to gain the confidence to begin interacting with them.

Furthermore, 50 individual projects incorporating community involvement were set up across these 3 areas and across 3 themes which were to improve:

• food choices
• access to physical activity
• access to data, to empower people to make better choices

Projects ranged from cookery lessons to information leaflets that were easier to understand than the standard Change4Life leaflets. The physical activity offer was collaborative and community-driven: the authority employed ‘activators’, physical activity specialist leads in each of the 3 areas, to ask the community what sports or activities they wanted to do. A 12-week children’s weight management programme was subsequently set up. After 3 years, a mini evaluation was carried out which identified some issues with data collection but also demonstrated that in relation to physical activity, parents understood the messages but were reluctant to engage. Additionally, the evaluation identified that the children’s weight management programme was serving children that had been participating for the last 3 years and some were still putting on weight. Further, it was noted that the programme only worked where there was parental engagement, otherwise behaviour did not change. Furthermore, the programme appeared to encourage dependency rather than empowering people to make healthy choices themselves. Following this evaluation, the children’s weight management service was decommissioned in favour of community engagement work.

A FWMP was established that required a commitment of engagement from families. This programme took part in participants’ homes as the local population did not want to do group work. This resulted in further barriers being identified. For example, some people did not own cookers, therefore, the programme could not implement many of the messages around healthy eating. As a result, the programme provided a basic cookery set and taught people how to cook at home. Activators met people within their homes to show them forms of physical activity that could be done at their local park. This project worked well until it came to the second phase when people were expected to transition to group support. Participants would still not engage with that type of support.

As a result, the service was rethought again. At the time this research took place the newest iteration had just started (in October 2017). It was aimed at parents with a high BMI (the children were not required to have a high BMI). Families (who again had to agree to engage) were allocated a complex case manager who acted as a single point of contact. The service provided more contact, although it was not as intensive and there was no set programme. The complex case manager could arrange for the family to receive the support they needed. For example, if they needed advice about diet, they could get advice from a dietitian, rather than undertake a 12-week course run by a dietitian. Contact with the complex case manager lasted for 11 months, and the intention was to upskill parents to make healthy choices for themselves.

In addition, following the evaluation, the most effective parts of the local Change4Life programme were considered business as usual. For example, roadshows continued in areas of high need and the activators worked across all areas and age groups. The public health team used a number of behaviour-change interventions. For example, at roadshows, they asked people to write a pledge of one thing that they could do to be healthier. They then sent them a reminder tailored to their pledge a few weeks later, asking them how it was going, if they needed help, and offering suggestions.

The approach was derived iteratively, based on evidence, evaluation and consultation with, and feedback from, the community. They learned the importance of collective working.

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. However, it was believed that ongoing monitoring would help to assess if it was successful in increasing parental engagement with the issue.

Further work involved continuing the newest iteration of services.

Yorkshire East Riding

The local authority put an iterative practice in place, including partnerships and schemes to increase whole family engagement, with an emphasis on the environment. The objective was to reduce levels of childhood obesity.

Yorkshire East Riding had a population of 337,696 in 2016. It’s a predominantly rural area with 333 settlements, ranging from large towns to small hamlets. East Riding of Yorkshire Council was one of the largest unitary authorities in the country.

Local approach

Yorkshire East Riding supported a number of initiatives to prevent and manage childhood obesity.

One programme called ‘Us Kids’ was for 5 to 10 year olds and their families. The programme provided a 10-week block of sessions and was running in 6 primary schools at the time this research took place. The programme had taken place with 32 families. They had a 78% completion rate, 88% of participants reported an increase in health knowledge and 64% an increase in confidence. It was oversubscribed and had a waiting list. A behaviour change officer (a work-place psychologist) assessed the scheme by talking to service users and examining the evidence base. This led to a revision of the service-level agreement and the weighing and measuring aspect was dropped to focus on removing barriers to participation. The thinking behind this was that the rest would follow in terms of getting to a healthy weight. It was difficult to assess which tier this may fall under, but the Director of public health (DPH) felt it was Tier 2, as it was an intervention.

At the time this research took place, Yorkshire East Riding were involved in developing a behaviour change website.

The Young Live Well scheme was accessible at all 10 leisure centres in the local authority, with a focus on considerably obese young people. Staff were highly trained in motivational interviewing and behavioural change, removing any potential barriers from the programme.

As a Tier 1 service, Change4Life and Skip4Life were promoted, with the latter being in 11 schools with great satisfaction ratings from children and teachers.

The Elevate services promoted coping skills and self-esteem to young people who may have used mental health services previously.

Rise was a programme of agility, balance and coordination for children and young people with special educational needs and disabilities.

‘Us girls’ was also advocated to promote physical and mental health in teenage girls. There was an awareness of the cross-cutting benefits on obesity of focusing on mental health and other needs.

A production through a theatre company to encourage primary school children to move from pre-contemplation to contemplation about healthy food choices and physical activity was funded. This came from discussions surrounding gaps in the council’s services and had been very successful for almost a year at the time this research took place. There was also a focus on involving parents, which had varying degrees of success. Nevertheless, due to its success, the project also delivered productions on drugs and alcohol.

A Families Information Service Hub acted as an information stop for all services for 0 to 19 year olds, including web-based ones for children and young people, parents or carers and professionals.

Work was being conducted towards incorporating active travel as part of local transport plans, with 14 strategies to encourage walking and cycling incorporated at the time this research took place. Modeshift Awards (Sustainable Travel Accreditation and Recognition for Schools) had more schools involved than anywhere else outside London. Seven bike libraries were also in operation, providing free loan bikes to children and families. Furthermore, the obesity strategy steering group had environmental representatives to address access.

The local authority was also trying to reduce sugar in vending machine drinks and were trying to make low-sugar drinks cheaper. A number of over-the-counter services had reduced the price of healthy choices. They identified calorie content and were trying to address high levels of fat, salt and sugar in recipes.

Most of the schemes provided by the area were in-house services, such as leisure and sports, play and arts services, some of which had won national awards. Further, all the programmes were shaped by a set of principles that included increasing participation and vulnerable children and young people. Therefore, many of these services were free or low cost and had planned exit routes for post intervention.

Deprivation

Areas of deprivation were a priority, with areas such as Bridlington, Withernsea and Goole a focus for services and schemes in place. The NCMP data was used to make this decision, which was overlaid with information on deprivation revealing a clear correlation. Weight Management Services also focused on those areas, although not exclusively.

National Child Measurement Programme

The NCMP was run by the Integrated Specialist Public Health Nursing service, which had just begun to mobilise at the time this research took place. The School Nursing Service sat within this with several nurses dedicated specifically to childhood obesity. Further, the public health team were designing a local version of Making Every Contact Count, and the school nurses had engaged with this. NCMP data was used to target web mapping services (WMS) in the schools with the greatest need, in order to normalise it within schools and ease take up. WMS in schools were open to a wider range of children and young people than those overweight or obese. This way, friends could do it together, removing stigma and encouraging participation.

Letters from NCMP followed the national template but included information on local services. A flyer was also included on local services, with 20 variations to ensure messages were catered to each specific local area. Feedback was not provided to GPs, but schools received routine feedback sent by PHE.

Outcome

It’s too early to say if this approach will help reduce childhood obesity in the area.

Further work

The DPH acknowledged that the previous weight strategy focused on individuals and families and that at the time this research took place they were focusing more widely on the environment. There were hopes to follow in the footsteps of neighbouring Hull in limiting new takeaways close to schools.