Meeting documents

Bath and North East Somerset Primary Care Trust

Bath and North East Somerset Council

September 2005

CONTENTS

1. Summary

2. Context and Local Profile

3. Prioritising Change

4. Moving forward- Strategic Direction

5. Implementation Plan

Summary

The incidence of Overweight and obesity is increasing significantly both nationally and locally. This is a problem for both individuals and society as obesity reduces quality of life and leads to an increased risk of illness and disease. The cost to the NHS in treating obesity related illness is very high.

The local incidence of obesity is broadly in line with the national picture but shows an above average increasing trend of obesity in men.

Obesity is preventable and reducing obesity is a key target for the NHS and is included in the planning and performance framework for 2005-09. It is a principal component of the public health plan, Choosing Health. The priority target for the NHS is to halt the increase of obesity in children under 11. In addition it is also necessary to acknowledge the need for treatment interventions in those who are already obese. These two categories: prevention and treatment, define the pathways of intervention which need to be established.

Bringing down the incidence of obesity means we need to ensure that physical activity levels increase and energy intake reduces. In practice this means enabling opportunities for active leisure and promoting the uptake of balanced dietary behaviours in the population. Other organisations are also interested in these two objectives and have targets relating to their achievement. Principal amongst these organisations are Sport England, through the school sports partnership and the local Authority through active leisure, transport and environmental health. Making progress towards these objectives needs a partnership approach focused around the NHS, other partner agencies and other stakeholder groups including the work already underway in Diabetes and Coronary Heart Disease.

To direct the partnership an agreed strategy is required which is in line with other strategic plans and relevant National Service Frameworks. The obesity strategy needs to fulfil the following aim:

To improve the health of local people through reducing obesity and promoting lifestyle behaviors which sustain healthy weight.

In achieving this it is necessary to focus activity within 4 principal objectives:

Developing and maintaining the partnership

Establishing the local profile, prioritising need, monitoring activity and reviewing performance

Ensuring prevention initiatives

Ensuring treatment initiatives

The strategy contains a detailed implementation plan which is described below and which directs practical project based actions to progress the stated objectives. The partnership needs to ensure delivery through performance management and regular review. This will now be progressed.

Context and local profile

Obesity

Obesity and overweight are conditions characterised by an excess of fat in the body. These conditions are important from a health point of view because they are associated with ill-health and shortened life expectancy as well as poor quality of life.

Overweight and obesity arise because of a prolonged imbalance in the amount of energy consumed (as food) and the amount of energy expended (through being active). Our bodies are naturally well adapted to storing excess energy as fat where we eat more than we burn off. Societal pressures that promote obesity are the increased availability of foods and drinks with high energy contents (due to high fat and sugar contents) and a decrease in the amount of physical activity undertaken (less manual working, less walking and cycling not balanced by increased physical activities in leisure time).

Obesity and overweight are usually measured as Body Mass Index (BMI) calculated by dividing weight in kilogrammes by height in metres squared:

BMI = kg / m²

The BMI gives an indication of the amount of fat in the body with a higher BMI associated with more body fat. BMIs are categorised according to the risk of health problems at each level (Table 1).

Table 1 - World Health Organisation classification of overweight and obesity

Based on World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: WHO, 1997

In general the risk of health problems starts to be seen in those who are overweight and increases thereafter. However, health risk does not increase in a linear fashion with increasing BMI so that those with higher BMIs are at vastly increased risk of serious health problems compared with those who have only a mildly increased BMI. In practical terms those who are morbidly obese will inevitably suffer from ill-health due to their increased weight and those who are obese are more likely than not to suffer ill-health.

The most important health risks associated with overweight and obesity are Type 2 diabetes, coronary heart disease, high blood pressure and stroke, and premature wear of the joints (osteo-arthritis) particularly of the knees. Controlling weight and preventing weight gain can prevent these conditions from arising in many individuals. In those with established health problems reducing weight and maintaining a new reduced weight can make it easier to control existing conditions or can even lead to significant improvements in health.

Table 2 - Health problems associated with obesity

Overweight and Obesity in the adult population

Since 1980 the prevalence of obesity has nearly trebled in the UK and is continuing to increase. Figures from the Health Survey for England show that since 1994 whereas the proportion of adults that are overweight has remained almost constant (over 2 in 5 (45%) men and 1 in 3 (33%) women) rates of obesity in the population have continued to rise and are now at over 1 in 5 in men (21%) and women (22%).

The smallest area for which we currently have figures that might tell us the extent of the problem in Bath and North East Somerset is the Avon Gloucestershire and Wiltshire (AGW) Strategic Health Authority area. Within AGW nearly half of men (47%) and over 1 in 3 women (37%) are overweight. Nearly 1 in 5 men (18%) and women (17%) are obese. Of particular concern locally is that the number of men who are obese is increasing at a faster rate than for England as a whole.

Levels of obesity and overweight in the population are not routinely monitored at a local level although this is changing with rapidly improving collection of data at general practice level. Estimates of the level of adult obesity at ward level in BANES suggest that the highest levels are found in Paulton, Midsomer Norton and Radstock and in the `South West triangle' (Twerton and Southdown) and that levels in those areas may be twice those in Bathwick and Landsdown.

Overweight and Obesity in Children

For children, new figures from the Department of Health were released in April 2005. These show that in England as a whole more than 1 in 4 children are now overweight or obese at the time they begin their secondary schooling. The percentage of children aged 2 to 10 who are overweight and obese rose from 22.7% in 1995 to 27.7% in 2003 with the largest increases seen in the 8 to 10 year olds. The levels of obesity in boys and girls were similar.

There is a marked social gradient in overweight and obesity in children. Children in deprived areas or from families with lower incomes are more likely to be overweight or obese. The highest levels of childhood obesity are seen in inner city areas. Parental overweight or obesity is the strongest predictor for these conditions in children reflecting the importance of tackling whole families in dealing with childhood obesity.

Locally, there is not routine monitoring of obesity in children and this is something that will be addressed as part of the new child health promotion approach outlined in the White Paper 93Choosing Health94. Nonetheless height and weight are routinely recorded at primary school entry. From this we know that locally there is a worrying trend to increasing overweight in children at school entry (particularly among boys). Additionally, in more recent years there has been a sharp upward trend in the levels of obesity that we have seen among children starting school.

The Cost of Obesity to Bath and North East Somerset Primary Care Trust

The total costs to the NHS of treating obesity and its related conditions (i.e. treating those with a BMI over 30) are conservatively estimated at between 2.3 to 2.6% of NHS spending on direct patient care by the House of Commons Health Committee using National Audit Office methodology. For B&NES this would mean that we were spending more than£4 million each year on treating obesity and its consequences.

Costs related to treating the population who are overweight are more difficult to estimate. However, a range of sources would support the assertion that the direct costs of treating overweight and its consequences in the NHS are similar to those for treating obesity. This means that another£4million locally is being spent on dealing with the health consequences of overweight.

The NHS within B&NES is spending £8 million each year treating overweight and obesity.

These costs are the direct costs that the NHS bears in dealing with the health consequences and do not take into account spending on social care or the wider indirect costs borne by the local economy (such as loss of earnings and productivity due to sickness) which are estimated by the National Audit Office to be as much as three to four time times greater than the healthcare costs. This would put the total cost of obesity and overweight to the local economy at over£30 million each year.

Prioritising Change

In recent years a focus on activity and healthy eating has been developing through both Local Authority and NHS policy directives. As an outcome local agencies are currently working towards the achievement of a range of identified targets. These are highlighted below. Targets have emerged through National Service Frameworks, policy guidelines, the planning and performance framework 2005-08 and the Choosing Health white paper. In addition there are other generic programmes that potentially impact on obesity including the Child Health Promotion Programme, travel plans and green space actions. In identifying the specific key targets these wider programmes are not included for reasons of clarity and brevity but they will remain an important context.

The Targets:

Coronary Heart Disease NSF

All NHS bodies, working closely with LA's, will have agreed and be contributing to the delivery of the local programme of effective policies on:

- Reducing overweight and obesity

They will have quantitative data no more than 12 months old about the implementation of the policies on:

- Promoting healthy eating, promoting physical activity and reducing overweight and obesity.

Children and Young People's NSF

Healthy Diets and Active Lives:

The Royal College of Paediatrics and Child Health and the National Obesity Forum have published guidance on weight management in children and adolescents (available at www.rcpch.ac.uk). Primary Care Providers should provide parents with advice and support on the growth of their children, promote physical activity and healthy diets with plenty of fruit and vegetables and limited sugar, salt and animal fats, as well as managing those identified as overweight or obese.

Diabetes NSF Delivery Plan

Prevention of Type 2 diabetes - Standard 1

The NHS will develop, implement and monitor strategies to reduce the risk of developing Type 2 diabetes in the population. This can be reduced by preventing and reducing the prevalence of overweight and obesity and the prevalence of central obesity.

In primary care, update practice-based registers so that patients with CHD and diabetes continue to receive appropriate advice and treatment in line with NSF standards and by March 2006, ensure practice-based registers and systematic treatment regimens, including appropriate advice on diet and physical activity cover the majority of patients at high risk of CHD, particularly those with hypertension, diabetes and a body mass index (BMI) greater than 30.

Planning and performance framework & Choosing Health

The Public Service Agreement (PSA) targets are reproduced in the following table along with Choosing Health and other policy objectives relevant to obesity. Each target is given a lead individual to take responsibility for monitoring the target development and advising on its requirement.

The table contains a summary of principal targets with specific reference to obesity originating within Choosing Health and other primary policy guidance

Moving forward- Strategic Direction

Taking action to address national and local objectives needs to be shaped and contained within a framework of priority, organisation and delivery. This is described within the following aims, methods and approaches encompassing both preventative and management initiatives.

Strategic Aim

Through interventions based on prevention and management, improve the health of local people by reducing obesity and enabling lifestyle behaviors which sustain healthy weight.

Strategic Objectives

Establish a baseline of obesity levels, continuously evaluate local position and monitor

Identify and deliver evidenced based programmes to prevent future obesity

Identify and deliver evidenced based programmes to manage obesity

Population Priorities

The strategy is applicable to all aspects of society and to the whole population with particular emphasis on:

Reducing Inequalities

Targeting Children

Targeting those at increased risk of disease

Approach

To both prevent and manage obesity the population needs to consume less energy and be more physically active. Action interventions which achieve this will address three broad categories:

Healthy school policies

Safe walking and cycling routes

Workplace activity initiatives

PHSE in schools

Removing barriers through localised health education and promotion

Media wide campaign & publicity

Sports and games in schools

Community based initiatives re cooking diet and walking

Motivational counseling and group based initiatives

Principles

The strategy will be progressed with consideration to the following key principles:

The PCT will lead the obesity strategy

The strategy will lead to specific actions for implementation

Actions will be developed prioritised and agreed through a multi-agency partnership

Agreed actions will be based on reliable up-to-date evidence and guidelines

Agreed actions will target priority groups, promote equal access and address health inequalities.

Monitoring and evaluation is an integral part of all work.

Key links to other strategies will be identified and actively pursued

Key staff groups and influential partners will be involved in the further development and implementation of the strategy, to ensure ownership

Local communities and stakeholder groups are empowered to make choices regarding physical activity and healthy eating, and address the barriers to weight loss

Training and education is developed to ensure that there is consistent advice and best practice

Sustaining an Obesity Partnership

The Obesity Partnership will act as a decision making and steering group to advance the organisation of ideas and the production of change. The group will be chaired by the PCT and will be accountable to the boards and key bodies of each organisation represented. The partnership will expect to achieve participation from:

The Primary Care Trust

Other NHS Trusts

Other health providers

The Local Authority

Educational institutions

The Voluntary Sector

Local Council members

Primary care and community clinicians

Local media

Local commerce and industry

Linking Strategies

The prevention and management of obesity links with a wide range of both local and national strategies. The obesity strategy for B&NES will both take account and consult with these other strategic drivers. These include:

Choosing Health

The NHS Plan

The NSF for Coronary Heart Disease

The NSF for Diabetes

The NHS for Children

The NHS Cancer Plan

B&NES Community Strategy

B&NES Active Leisure Plan

Taking Action- the core elements of implementation

The partnership will adopt the 93Tackling Obesity - a toolbox for local partnership action94 as its guide in developing strategic direction and the Choosing Health Obesity Action Implementation Plan. Core elements of implementation comprise:

Local Needs Assessment

Resource Mapping

Priorities for Action

Strategies for change

Service developments

Performance review and monitoring

Capacity and Workforce

Delivering change in eating behaviors and an increase in physical activity will necessitate developments in a range of capacity and workforce areas over time. The strategy will work to both identify and specify these resource needs. Areas of review will include the roles of:

Health Visitors and primary care staff

Community Dieticians

Physical Activity and healthy eating Coordinators

School Nurses

Exercise referral scheme providers

Health Trainers

Implementation Plan

A detailed Implementation Plan to progress the obesity strategy is shown below.

Delivering the strategy and maintaining the partnership

Knowing where we are

Objective 1

Establish position evaluate and monitor

Establish inequalities and priorities

Enabling Prevention

Objective 2

Deliver evidence based programmes to prevent obesity

Enabling Treatment/Management

Objective 3

Deliver evidence based programmes to manage obesity

Delivering Principle Projects

The action plan points to 5 key projects that will require additional partnership and development work to be progressed by individual leads. These projects will lead to further detailed interventions within each area.