1. The New Public Health Landscape, its impact on Local Authorities and the obesity agenda Angela Baker

2. Purpose of the session This session will
Share knowledge of the changes to the public health system
 Commissioning for Obesity, a new landscape
 Key local figures and organisations and how to engage with them
But first, who are we….
Highlight what we want to get out of the day

3. Public Health England
Exists to protect and improve the nation's health and wellbeing, and reduce health inequalities. It does this through advocacy, partnerships, world-class science, knowledge and intelligence, and the delivery of specialist public health services. PHE is an operationally autonomous executive agency of the Department of Health.
I am a member of the Thames Valley PHEC. There are three teams within the centre, Health Protection, Healthcare Public Health and Health Improvement. We all work together to achieve the above.

4. 18 Strategic Health Authority
Dept of Health
18 Strategic Health Authority
151 Primary Care Trusts
Providers
Old Structure
A History Lesson
Pre 2012 Health and Social Care Act we had a structure which looked like this. It was hierarchical. PCT’s were responsible for commissioning health services generally though bundled contracts

5. Current Structure Dept of Health Public Health England NHS England
NHS E Regions
(X4)
NHS E Local Area Teams
(X24)
Clinical Commissioning Groups
Public Health Local Authority
Public Health England Regions (4)
Public Health England Centres (15)

6. Obesity – what do we know?

7. Threat of obesity
Over 2 billion adults, nearly a third of the worlds population and an estimated 170 million children are overweight or obese
Social norm in England with 2/3rd of adults either overweight or obese
Adults are not judging their weight and that of their children accurately
For some adults losing weight is not a priority – most overweight or obese men are not actively looking to lose weight
Locally there is a variation in obesity rates
Obesity is a clear risk to the health and well-being of children and adults and in 2013, the global burden of disease report highlighted that high body mass index, poor diets and lack of physical activity are key risk factors for morbidity and increased mortality.
Poor diet and its consequences including overweight/obesity, cardiovascular disease, diabetes and some cancers mean that diet is one of the key priories for public health to tackle.
Prevalence of Obesity
The prevalence of obesity across England is too high and collaboratively we need to act.
Currently:
22% of 4-5 year old children and
33% of year old children are overweight or obese.
67% of men and 57% of women are obese or overweight.
Reference:
Reception age 4-5 years. Year 6 age years.
National Child Measurement Programme data source: Health and Social Care Information Centre
Adults - Health Survey for England
Obesity and Healthy Weight: An Update

8. Obesity prevalence by deprivation decile National Child Measurement Programme 2012/13
Social Gradients
Clear social gradients in child obesity are evident and the inequalities gap in child obesity appears to be widening. In younger children (age 4-5 years) obesity appears to be decreasing at the fastest rate among the least deprived children with only signs of stabilisation or small decreases among the most deprived children.
In older children (age years) the stats are much more damning with levels of obesity increasing over time among the most deprived – prevalence for the least deprived children remains relatively stable.
The levels of severely obese children is of concern as they are at high risk of developing early manifestations of chronic diseases and are much more likely to remain severely obese into adulthood. In 2012/13 it is estimated that over 12, year olds and around 17, year olds are suffering from severe obesity.
Obesity prevalence in the most deprived 10% of the population is approximately twice that among in the least deprived 10%.
Data source: Health and Social Care Information Centre,
Child obesity: BMI ≥ 95th centile of the UK90 growth reference
Obesity and Healthy Weight: An Update

9. Costs of diet, obesity and physical inactivity
Poor diet and its consequences including overweight/obesity, cardiovascular disease, diabetes and some cancers make diet one of the key priorities for public health to tackle.
70,000 premature deaths prevented in the UK if nutritional recommendations on salt, saturated fat and added sugar were matched
Economic burden of diet related ill health estimated at £5.8 billion to the NHS
Cost of overweight and obesity to the NHS about £5.1 billion
Physical inactivity contributes to almost 1 in 10 premature deaths, equal to smoking
Physical inactivity is estimated to cost the UK £7.5bn annually (incl. £1bn to NHS)
Obesity is a major cause of chronic disease, including increase the risk of type 2 diabetes, cardio-vascular disease and some cancers and is a leading cause of morbidity and premature mortality in England.
The health issues associated with people being overweight and obese costs the NHS over £5 billion per year. There are also direct costs to social care and a negative impact on individual wellbeing.
Physical inactivity contributes to almost 1 in 10 premature deaths, equal to the impact of smoking. (WHO (2011)). A 20-year UK study following almost 5,000 adults showed and showed equal all-cause mortality ratios for smoking and physical inactivity. Physical activity was the greatest risk factor for cardiovascular disease, greater than smoking
Estimated costs to the UK of £1.06 billion in NHS services, and £5.5 billion in lost productivity and £1 billion in premature mortality of the working age population in England.
References:
Bullet 2 - Strategy Unit 2008
Bullet 3 &4 - Scarborough et al 2011
Obesity and Healthy Weight: An Update

10. Current shared ambition
National ambition (Call to Action on Obesity)
By 2020:
a sustained downward trend in the level of excess weight in children
a downward trend in the level of excess weight averaged across all adults
Across the nation there is a breadth of action to help families and communities to tackle poor diets, inactivity and promote a healthy weight.
Our collective action, however, has yet to make the impact needed to shift the population’s behaviour and it is time for us to work together on realising the step-change in action that we know is required if we are to make significant headway in tackling obesity.
Obesity is a clear risk to the health and well-being of children and adults and in 2013, the global burden of disease report highlighted that high body mass index, poor diets and lack of physical activity are key risk factors for morbidity and increased mortality.
Poor diet and its consequences including overweight/obesity, cardiovascular disease, diabetes and some cancers mean that diet is one of the key priories for public health to tackle.
PHE’s priorities’
Acknowledge that the our ‘priorities’ on obesity merges with the joint DH/PHE ambition for It is clear that we need to achieve the 2020 ambition if we are to achieve a 10 year ambition to halve child obesity.
The current shared ambition across government is to achieve a downward trend in child and adult excess weight by 2020 and the intent of this shared big ambition for obesity will help to re-galvanise our efforts to achieving this. We firmly believe there is a consensus to look further ahead – the obesity epidemic has taken hold over the last twenty to thirty years and it is now time to begin to plan a much longer and sustained approach.
It is evident that obesity as a risk factor for adult’s health is unlikely to diminish in its seriousness over the next 20 years. Modelling projections of obesity, undertaken as part of development of the Health and Well-being framework, suggest that in best case scenario obesity is projected to decrease from 28% in 2009 to 18% in 2034, whilst the proportion overweight will remain stable at around 32%. In the worst case scenario obesity is projected to increase to 43%, whilst overweight remains stable at around 30%.
Effective actions to reverse child and adult obesity will take time to develop and implement, the impact and magnitude of which will take time to realise and will change over the course of time. We recognise that much more attention is needed to deliver action that is sustainable, scalable and has the penetration to mobilise population change within the most deprived communities.
What we need from this programme of co-production is an ambition on obesity, which will help galvanise collective responsibility and secure credible investment to deliver the sustained and effective breadth of actions required to help shift the population’s weight in a healthier direction. A specific ambition to herald the next decade or so of action will drive us in the right direction and enable us to deliver a framework of action to tackle obesity and help children and adults maintain a lifelong healthy weight.
Obesity and Healthy Weight: An Update
Obesity and Healthy Weight: An Update

11. Tackling obesity: one of PHE’s seven priorities
Taken from PHE’s Priorities document: From evidence into action: opportunities to protect and improve the nation’s health.
Outcome: ‘An increase in the proportion of children leaving primary school with a healthy weight, accompanied by a reduction in levels of excess weight in adults.’
Obesity and Healthy Weight: An Update

12. Action at all levels Obesity and Healthy Weight: An Update
The model illustrates that action is required at all levels.
It builds on and reflects the findings from the DsPH survey and local engagement events which forms the basis of the obesity work plan.
PHE needs to respond and deliver action across the 4 different levels: national, centre, local and individual/family.
We need to consider the ‘enablers’ to assist – partnerships, communications, engagement, resources, advocate, and political leadership (all relevant at a national and local level).
Potential constraints/barriers include wider environmental policy and societal norms, social attitudes and level of engagement.
Working together across PHE
It is important for all the partners and PHE teams and centres to work together in the long term to sustain the work, building in resilience, advocacy, engagement and leadership around obesity.
Teams across PHE are working together and interacting on programmes of work as the Obesity Project Team.
PHE delivers its programmes, through teams working together across the life course and on specific subject areas. A range of teams make a significant contribution to the work on obesity including: Diet and Obesity; Obesity Knowledge and Intelligence, Children; Health Equity; Adults and Older People; and Regional and Centre teams, who also support local public health teams to deliver action to tackling obesity.
Obesity and Healthy Weight: An Update

13. Obesity work plan: five pillars for action - 2014/15
Where future generations live in an environment, which promotes healthy weight and wellbeing as the norm and makes it easier for people to choose healthier diets and active lifestyles
1.Systems Leadership
Influence local & national leaders
raise the national debate
influence political ambition
maximise communication
2.Community Engagement
enable behaviour change through social marketing
drive social investment through local action
support communities with tools on healthy eating & getting active to help reduce health inequalities
3.Monitoring & Evidence Base
enhance surveillance, analysis & signposting of data
tailor evidence to meet local needs - PHOF
support effective commissioning & evaluation
develop & communicate research to inform strategy
promote evidence of good practice
4.Supporting Delivery
support the obesity care pathway
work with DsPH & CCGs
support commissioning
practical tools to help deliver healthier places; enable active travel
5.Obesogenic Environment
develop long term, evidence based strategy to deliver a whole system approach to tackle the root causes of obesity and address health inequalities
Building on the Foresight work we are shaping and sharing our framework, which comprises of five pillars of action.
It is clear that progress is only likely if the health and public health system leaders at national and local level are joined in collaboration by the third sector, the academic and research community and commercial enterprises. We now need to build this consensus and shared commitment to tackling obesity.
We believe that this framework for action provides the foundations for the next phase of development, which is the co-production of our proposed shared ambition and key actions.
More fundamentally any action needs to consider the population’s mood and appetite for intervention, whether treatment or preventative, in what some see firmly as individual rather governmental responsibility.
Tackle obesity, address the inequalities associated with obesity and improve wellbeing
Obesity and Healthy Weight: An Update

14. It is about real people
Wrap around care and delivery of treatment services to support people
Business &
3rd sector
Communities
& local people
Prevention
Awareness/ Recognition
Treatment
referral
support
services
Local authority action –
planning, leisure, social
care & environmental
Schools &
early years
Challenge for PHE is to work towards providing wrap around care for individuals who are obese/overweight
Links to other national ambitions for the public’s health, making every contact count
PHE’s role to build in systems resilience
Need to improve the 3 stages of the model
All need to work together to find out what is important to real people and families.
Invest in each stage so the system works for real people and families in tackling obesity.
GP’s, local authority experts, CCG’s etc bring together to support.
Needs to be about real people – coming back to what is most important which is those people who are overweight and obese and recognise what these people need.
It comes back to the individual and wrap around care
Prevent people from becoming overweight and obese in the first place
Requires sustained action over a long period of time at both a local and national level – we won’t always see immediate impact
Need to build in advocacy, resilience and engagement to keep obesity in peoples minds and build into PHE’s work.
People's mind-set around obesity needs to change. Learning from the ground up to benefit each others work – create a social movement, building in resilience and changing peoples mind-set is important.
CCG’S & NHS
Obesity and Healthy Weight: An Update

15. Over the next 18 months, PHE will
work with NHS England to implement the commitments to tackling obesity set out in the NHS Five Year Forward View
produce an independent report for government on sugar and diet, including evidence
reviews on fiscal measures and promotions and advice from the Scientific Advisory Committee on Nutrition
publish the evidence-based Everybody Active, Every Day framework30 and refresh the eatwell plate and 5 a day approach
run the New Year healthy eating campaign and summer physical activity campaign, and increase the number of families signed up to Change4Life by 500,000
support local authorities to deliver whole system approaches to tackle obesity, including through supporting healthier and more sustainable food procurement
Taken from PHE’s Priorities document: From evidence into action: opportunities to protect and improve the nation’s health.
Public Health England: Obesity Update

16. Whole systems approach
Obesity and Healthy Weight: An Update

17. Commissioning of Tier 3 and 4
NHS England and PHE convened a Joined Up Commissioning Responsibilities Working Group following NHS England’s published clinical commissioning policy on the specialised management of severe and complex obesity in April 2013.
A report of the conclusions published, proposed that CCGs would formally take on the primary commissioning responsibility for tier 3 obesity services.
Informal consultation indicated that clarity on responsibility for Tier 3 commissioning was welcomed, and further information on commissioning responsibility on local implementation was required.
‘Commissioning intentions 2015/16 for Prescribed Specialised Services’ published on 30 September Recommendations were that the following services currently commissioned by NHS England should in future be commissioned by CCGs:
renal dialysis (excluding encapsulating sclerosing peritonitis surgery)
surgery for morbid obesity
Once a ministerial decision is confirmed, any change in responsible commissioner will need to be reflected within NHS England and CCG contracts with providers.
While not obvious from the written text, conversations within NHS England have reflected the expectation that much of what currently sits under the specialised commissioning portfolio of NHS England will be co-commissioned with CCGs in the future. It is suggested that renal dialysis and surgery for morbid obesity will serve as pilot work streams for the future co-commissioning model.
Initial discussions are focussing on the evolving role of the NHS England Severe and Complex Obesity Clinical Reference Group as we look to develop the co-commissioning model. If CCGs are involved in the co-commissioning of tier 4 obesity services in the future, there could be great opportunity for developing more effective integration between tier 3 and tier 4 obesity services, in terms of both integrated commissioning and integrated service delivery by providers.
Obesity and Healthy Weight: An Update

18. Not the only ones in the field?
Who holds the power in your particular area, for what you want to do?
Sports Network, become a member?
Where can you add value to other partners work?
Which counsellors can you get involved?
Is there a clinician you can engage with?
Make a case about what you can offer and the benfits?
Assume nothing

20. Making the Case - ROI Seven tools, all do a different thing,
Briefing Paper can be found at
Most important thing is to work out what you need to know
NICE Guidance
Build evaluation of programmes into the planning so that you collect the right data and information

21. Angela Baker, Public Health Consultant in Health Improvement