Agenda item

Obesity in Herefordshire

To present background information for the committee to consider the ways in which the council and partners currently tackle obesity in the local population and to make any recommendations around future provision.


On behalf of the committee, the Chairperson commented that this was an excellent report, thanked the Director of Public Health and the other officers involved for the high standard of work, and welcomed the participants to the meeting.


The Leader of the Council commented on the implications of people being overweight for the health and care system, and the need to take full advantage of the opportunities for walking and exercising in the county.


The Director of Public Health gave a presentation on ‘Tackling Obesity’, as published in a supplement to the agenda (link to the presentation).  This included slides showing:


·             Epidemiology statistics, identifying that 67% of adults in Herefordshire were overweight or obese (2020/21);


·             A system map from the Foresight, Tackling Obesities: Future Choices – Project report (2007) (link to the report), illustrating different determinants that can lead and influence body weight; an overview of current action to tackle obesity, highlighting national and local programmes, and recognising that there were some gaps in weight management support across Herefordshire’s child and adult healthy weight pathways;


·             An infographic reflecting the different level of healthy weight interventions from a universal provision through to services to meet individual care needs, and across life stages; and


·             A summary of the recommendations detailed in the conclusion and key areas for policy development section of Appendix A (agenda page 39).


The principal points of the discussion included:


1.           Professor Gately commented that: the system map demonstrated the complexity of the interactions between the key variables; the needs, strengths and challenges of each area were different and had to be considered at a local level; it was clear from the evidence that investment in a good provision of services was critical; a whole systems approach needed to be relevant to the local authority, to be cognisant of recent public health, political and economic events, and to be prepared for the emergence of new issues; in addition to reflecting the key strategic goals of the council and of the health system, there was a need to involve other local stakeholders, such as businesses and education providers; a series of workshops could help to pull information together and develop a plan; local practitioners could follow the Whole systems approach to obesity: A guide to support local approaches to promoting a healthy weight (2019) (link to the guide), with appropriate support and resources committed to do it well.


2.           The Chairperson commented on the need for improved coordination to achieve seamless service provision and questioned whether a healthy weight strategy, using the whole systems approach, would be beneficial. 


The Director of Public Health commented on the work already being undertaken, including on the physical activity strategy and in relation to sustainable food, and on the need to avoid duplication.  The workshop approach advocated by the guide could provide an opportunity for collating key information but also to identify where to best focus effort and maximise value.


The Chairperson suggested that a healthy weight strategy could help to join up existing workstreams but also explore other areas of synergy within the functions of the local authority and its partners.  It was proposed that it be recommended to the executive that consideration be given to the development of a strategy, using a whole systems approach.  A committee member added that this should include all ages.


3.           The Chairperson expressed support for the suggested recommendation ‘Work with the planning department to develop and implement a Health Impact Assessment Tool to ensure health is considered in all planning decisions’.


4.           Professor Gately said that the best, current evidence of the success of a whole system approach was in Amsterdam, where there had been dramatic reductions in childhood obesity in the last eight years.  The need to bring stakeholders together and align behind primary goals was emphasised.


5.           A committee member felt that more investment was needed in free sports and leisure provision for children and young people.


The Director of Public Health noted the importance of the early years, particularly given the difficulty for people with obesity to get back to a healthy body weight.  However, universal provision did not necessary result in uptake from those people most in need of such initiatives and this could widen inequalities.


The Chairperson commented that it could be more effective to focus support on those individuals who were already struggling with a healthy body weight, regardless of socio-economic background.


It was reported that an evaluation of the ‘Get Active’ initiative was due in November 2022.


A committee member considered that a package was needed for schools on a range of health and wellbeing issues, including membership opportunities for sports and leisure facilities.


6.           A committee member, referring to Figure 7 ‘Proportion of referrals to the Health Trainers Service based on deprivation quintile’ (agenda page 33), questioned the reason for a lower level of referrals from the most deprived areas. 


In response, the Talk Community Health and Wellbeing Manager said that: deprived areas were targeted but resources were limited; community engagement encouraged people to access the service directly; the majority of referrals came through GPs; higher numbers of people accessed smoking cessation services, reducing capacity for work on weight management; and the service was working with NHS bodies to strengthen the support that could be offered.


The Chief Officer of Healthwatch commented that the most adversely affected people in the most deprived areas often had other life challenges, inhibiting their ability to obtain support.  Therefore, there was a need to consider investing resources disproportionately in order to work with the people most in need.  The Chief Officer added that communities needed to be involved as part of a whole systems approach.


The Talk Community Health and Wellbeing Manager commented further on the challenges arising from referrals into the service and on the work being undertaken in partnership with NHS bodies to manage demand.


7.           In response to questions from the Vice-Chairperson, the Director of Public Health said: it was understood that the situation was getting worse; a higher proportion of children were becoming overweight or obese; more adults were becoming morbidly obese, putting additional stress on health and social care; and there were issues with body mass index (BMI) but it was still a reliable measurement at a population level.


Professor Gately said that: excess weight had increased during the COVID-19 pandemic and this would a have a lasting effect; people living with obesity were getting heavier; the gap between the more affluent and the less affluent was widening; appropriate interventions were needed for each individual; and communities with more vulnerabilities were at higher risk.


8.           In response to a question about people’s self-perceptions, the Director of Public Health commented on the possible normalisation of heavier body weights and drew attention to the suggested recommendation ‘Develop a training package around ‘raising the issue of weight’ for health practitioners and other front line workers to give them confidence to identify and elicit positive behaviour change in individuals’.  The complexity of the situation and the need to work together was emphasised, including with the commercial sector.


9.           A committee member, noting increasing numbers of children classified as overweight or obese, commented on the long term health implications, particularly in view of declining levels of physical activity and intake of fruits and vegetables.


The Director of Public Health reported that the National Child Measurement Programme data showed that the prevalence of obesity approximately doubled between reception year and year 6.  The Director said that there was lots of good working going on but there was not a healthy schools programme currently.  It was noted that there were other life transition points but the early years provided good opportunities for intervention.


The Talk Community Health and Wellbeing Manager said that the Health Trainers Service was client centred and provided support over a twelve week period, and additional investment would be needed to increase capacity and provide longer term support.


10.        The Vice-Chairperson noted that ‘There is some evidence that mothers who breastfeed provide their child with protection against excess weight in later life’ (agenda page 25) and commented on the need for health practitioners to communicate important messages but also to tackle health myths.


It was also commented that more could be done to encourage children to walk the last mile to school.


The Director of Public Health said that the cumulative effect of interventions and changes to behaviours were more likely to have an overall population impact.


The Primary Care Commissioning Manager commented on the value of asset mapping in a whole system approach and, as an example, noted that a junior parkrun initiative had started in Herefordshire recently.


In response to a comment from the Vice-Chairperson, the Director of Public Health acknowledged that calorific intake was driving the obesity epidemic but physical activity was beneficial for the health and wellbeing of everyone.


11.        In response a question from a committee member about the perceived difficulty for people to manage weight as they aged, Professor Gately commented that critical phases were not necessarily influenced by underlying biological factors but more by social, emotional, psychological and environmental factors.  It was noted that all the stakeholders recognised the complexities and now needed to consider how to prioritise and corral efforts and resources to meet the needs of the population in Herefordshire, with a coherent plan with a clear.


12.        The Chairperson noted that the Get Active initiative increased access to leisure facilities but there should also be a focus on physical activity in the countryside.  However, traditional stiles prevented many potential users, including dog walkers, from accessing Public Rights of Way.  Therefore, the Chairperson suggested a recommendation to invite the executive to explore the potential to require any new or replacement barriers to improve access for the less able.


13.        The Chairperson also proposed a recommendation to invite the executive to consider extending free access to sports and leisure facilities to care leavers up until they reach the age of 25.


14.        A committee member suggested that, in view of the amount of open space owned by the council, consideration could be given to providing support to parkrun and other initiatives.


15.        The Lead for Prevention and Personalised Care commented on the need for an integrated approach and for co-production with local people, that the NHS Long Term Plan identified a number of actions on obesity, and it was appreciated that a ‘one size fits all’ approach did not work.  The Project Manager for Children and Young People Transformation emphasised the need to focus on prevention and the value of an all ages approach.


16.        The Chairperson questioned the effectiveness of approach to one-off grant funding in terms of embedding change and suggested that a strategy could help to identify a pipeline of initiatives which could be supported as and when resources became available.  The Chairperson also commented on the need for robust monitoring.


17.        A committee member drew attention to statement in the report, that ‘Herefordshire does not currently have a bespoke Tier 3 service with the referral pathway to the Gloucestershire Hospitals NHS Foundation Trust’ (agenda page 34), and this could be a major obstacle to access. 


The Lead for Prevention and Personalised Care said that some patients were also referred to Worcestershire based on patient choice and options for provision within Herefordshire could be discussed further with the Integrated Care Board. 


The Project Manager for Children and Young People Transformation advised that Tier 3 specialist weight management services for children across the region were based in Birmingham, as it would not be effective to provide services locally due to the low numbers involved.


The Project Manager for Children and Young People Transformation acknowledged that there was a gap between Tier 1 and Tier 2 services, commented on capacity issues in the school nursing and health visiting workforce, and said that other forms of provision were being explored, such as family coaching.


The Director of Public Health commented that Tier 3 services needed to be psychologically led given the complexities which sometimes included trauma experienced in childhood.


The Director of Public Health said that there was a need to understand better why some parents did not wish to access services for their children.


The Chairperson considered that a strategy could help to inform the balance of investment in terms of widespread campaigns and other initiatives which focussed attention on the clustering of health behaviours.


Professor Gately commented on the limited numbers that could access the Complications from Excess Weight (CEW) clinics for children, as this initiative focussed on the medical management of the comorbidities of obesity in certain pilot areas.  It was noted that around 450,000 children would typically access Tier 3 services in England, therefore it would be justifiable to have a Tier 3 service in each local system.  Professor Gately said that he considered the move away from interventions on childhood obesity to be a backward step.


18.        The Vice-Chairperson commented on the need for a ‘One Health’ approach given that the health of people was closely connected to the health of animals, with many pets also becoming increasingly overweight.


19.        The Leader of the Council made observations about challenges in terms of: messaging, including the advice given by health workers in relation to baby weight; declining physical education and sport in schools, with limited involvement by teachers not directly responsible for lessons; and the waning participation of pupils in PE in the Sixth Form.  The Leader noted the potential value of a whole systems approach, with appropriate early interventions.


The Chairperson drew attention to the summary of the recommendations detailed in the conclusion and key areas for policy development section of Appendix A (agenda page 39/40).  The committee considered additional recommendations, commenting further on: the appropriate use of language to ensure that people were not stigmatised; the need for robust monitoring and data quality; making Public Rights of Way easier to access for the less able and for the purposes of dog walking; encouraging children and young people to walk to education settings and to get involved in other physical activities; ensuring that grant funded initiatives were as coordinated and sustained as possible; and the importance of the relevant bodies taking ownership for the delivery of strategies.


Following a short adjournment, the following resolution was then agreed.



1.           That the proposals outlined in paragraph 11 (agenda page 39/40) of the Director of Public Health’s report be endorsed and be referred to Herefordshire Council’s Cabinet and to NHS Herefordshire and Worcestershire Integrated Care Board for consideration, along with a summary of the evidence considered and the observations of the committee; these proposals being:


i.             Embed healthy weight as a strategic priority across local organisations and agencies by working with all key partners to develop a greater understanding of the causes of obesity and how best to deliver collective action through a whole system approach


ii.           Assess the impact of the current gaps in the county’s weight management services in order to allocate sufficient resources as appropriate:


·             Tier 2 child and adult weight management services

·             Tier 3 child and adult weight management services – NHS/ICB priority

·             Tier 4 adult weight management service – NHS/ICB priority


iii.          Encourage health professionals and residents to identify ways in which patients can do more to help themselves through promotion of digital and self-help resources


iv.          Work with the planning department to develop and implement a Health Impact Assessment Tool to ensure health is considered in all planning decisions


v.           Improve the quality of data on weight management services and obesity across the life course with a particular focus on long-term outcomes


vi.          Develop a training package around ‘raising the issue of weight’ for health practitioners and other front line workers to give them confidence to identify and elicit positive behaviour change in individuals


vii.        Build on the Sustainable Food Partnership to deliver collective action through a systems approach


viii.      Undertake further mapping of weight management services (and compliance with NICE Guidance) and raising awareness of the Weight Management to health practitioners across the county, including the service offer, eligibility criteria etc


ix.          Consider a consistent approach to the type of language and media used to communicate about obesity, tailoring language to the situation and co-producing communications with intended audiences


2.           That Herefordshire Council and NHS partners develop a whole systems, Healthy Weight Strategy to coordinate and deliver actions for improved health outcomes;


3.           That a Health Schools Strategy, to include emotional, mental and physical wellbeing, be considered as a specific programme to engage and involve schools;


4.           That Herefordshire Council and NHS partners ensure that the Healthy Weight Strategy include key measures to effectively measure and evaluate the impact of the strategy over time;


5.           That the ‘Get Active’ fund programme evaluation be used to help inform the Healthy Weight Strategy;


6.           That free access to gyms services be made available to care leavers up to the age of 25;


7.           That Herefordshire Council take measures to improve access to Public Rights of Way / countryside footpaths; and


8.           That a Health Impact Assessment Tool be developed for use in planning policy to consider potential impacts on health and wellbeing of planning applications.

Supporting documents: