HC 1048-III Health CommitteeWritten evidence from MEND (PH 93)


MEND (Mind, Exercise, Nutrition… Do it!) will work with public, private, third sector and academic organisations to:

empower children and adults to become fitter, healthier and happier and to reach or maintain a healthy weight;

offer solutions that people can use throughout their lives to improve their fitness, health and self-esteem by providing the information and support they need to choose healthier foods and spend more time being active;

provide the knowledge, skills, resources and training that professionals and organisations need to:

prevent people from becoming unhealthy as a result of inactivity, injury or poor food choices; and

treat people who are above a healthy weight (and therefore more at risk of developing chronic diseases including cardio-vascular disease, type 2 diabetes and some cancers).

develop innovative ways to improve public health and encourage healthier lifestyles, using our extensive research.

Since being founded in 2004, MEND has helped more than 40,000 children and adults across the world to live fitter, healthier and happier lives. Our programmes, training and resources can be tailored to the communities where they are delivered and are developed using detailed research and evidence. We currently hold the largest volume of child weight management programme data in the world. In the UK, we have a 20-year research partnership with Great Ormond Street Hospital for Children NHS Trust and the University College London Institute of Child Health.

GP and provider representation on Health and Wellbeing Boards will be crucial in ensuring a joined up approach to public health.

Local Authorities are well placed to assume responsibility for commissioning obesity services but commissioners will need to be supported during the transition and thereafter to make good decisions.

To do this, central government should do the following:

provide a commissioning support pack specifically for obesity services comprising high quality obesity pathways, benchmarking data, suggested proxy outcome measures and cost data;

provide commissioners and providers with a national set of evidence which both should be required to use;

produce a clear set of standards by which providers can be evaluated;

produce a directory of approved obesity providers;

incentivise good practice; and

make it a requirement for Local Authorities to use e-procurement.

Children’s indicators must be included in the Public Health Outcomes Framework.

The ring fenced public health budget must be safeguarded to ensure it is translated into frontline services. What is more, budget allocations must shift to focus on targeted prevention and treatment where there is a strong evidence base, rather than traditional preventative methods with limited evidence and outcomes.

MEND strongly supports the inclusion of recommendations made by the Marmot Review team in Healthy People, Healthy Lives and hopes they will infiltrate all areas of public health policy.

The Future Role of Local Government in Public Health

1. We agree that Local Authorities are well placed to assume responsibility for commissioning obesity services. As the bodies responsible for many of the channels through which we can improve public health such as leisure centres, schools, housing and planning, they are well placed to formulate an all-systems strategy for tackling obesity which cross-cuts many impacting factors. This should increase their ability to improve outcomes for the population as a whole.

2. Health and wellbeing boards have the potential to provide a vital link between GP Consortia and the other various commissioners of public health interventions to achieve a joined up approach to improving public health. We hope that GP attendance will be made compulsory.

3. Healthy Lives, Healthy People iterates that providers may be invited to sit on the health and wellbeing board to advise on certain issues. We hope that this approach will be encouraged as providers can offer valuable advice on how to commission services effectively and efficiently.

Arrangements for Commissioning Public Health Services

4. Commissioners, especially those who are not specialists in child and adult weight management and obesity prevention, need to be supported during the transition in making rational decisions about which interventions to purchase and to do so in a timely manner. This support must be provided immediately, to ensure that services and capacity are not lost during the transition period, as well as being embedded in the medium and long obesity strategy. MEND recommend the following steps are taken:

4.1 Make it easy for commissioners to procure high quality interventions

A commissioning support pack—specifically for obesity services—should be developed to support PCTs, and then local health and wellbeing boards and GP consortia, in working together to commission obesity services. The support pack should build on existing good practice and include:

high quality obesity pathways—enabling commissioners to determine the nature of services that they may wish to commission There are many good local examples of this that can be publicised;

benchmarking data—allowing commissioners to both assess the relative need of their population and the relative performance of existing and candidate providers (NCMP data);

suggested proxy outcome measures—providing a framework to performance manage providers on clinically relevant indicators rather than process measures (National Obesity Observatory (NOO) Standard Evaluation Framework (SEF)); and

cost data—setting out (in the absence of a national tariff) what would be a reasonable cost for obesity interventions, when commissioning at scale is the most cost effective option, and what that scale should be. The Department of Health can gather this information in a comparable way nationally and publicise it.

Most of this can be collated swiftly from existing sources and we are happy to contribute in any way we can.

4.2 Ensure commissioners and providers use a national set of evidence

It is important that commissioning decisions are made on high quality evidence. In the past we have seen tender processes drag out for up to 12 months, caused partly by commissioners developing their own set of evidence. Building on the work previously carried out by the National Obesity Observatory the evidence base should be collated and made available through the NHS Evidence website, allowing commissioners to easily access consistent, high quality, information.

4.3 Produce a clear set of standards by which to evaluate providers

To date, relatively few child weight management tenders have included the ability to compare value for money on a like for like basis. To ensure high quality services are commissioned and provided, both providers and commissioners must know the standards of service expected of them, and commissioners must be able to compare providers like for like.

4.4 Produce a directory of obesity providers

Given the developing nature of obesity intervention provision it will be important to support commissioners in identifying suitable “any willing providers”. A directory of obesity providers should be developed, encompassing NHS, private sector and social enterprise providers. This should set out which choices of interventions should be guaranteed to all patients. It should also rate interventions by categories such as cost, cost effectiveness, evidence, outcomes, impact on health inequalities and success in reaching BME groups etc. This would allow commissioners to select the best intervention for their local area, based on the resources available to them and their JSNA, but without compromising on quality.

4.5 Incentivise good practice

Too often in the past the obesity services have been evaluated based on process and inputs, rather than on clinical outcomes. We believe this is fundamentally wrong. The strategy should set out how services and commissioners could be rewarded on the basis of the outcomes that they deliver. This incentivisation should be realistic and based on evidence, not, as demonstrated in one tender recently, putting a very large proportion of the contract at risk for outcomes far beyond those demonstrated anywhere in the literature. Mechanisms for achieving this could include use of the health premium, CQUINs type schemes, or the development of best practice tariffs. A NICE Quality Standard for childhood obesity should be developed, and children’s indicators should be included in the new Public Health Outcomes Framework.

4.6 Use of eProcurement

The cost to providers of bidding for and winning Local Authority contracts can be considerable when the process involves a pre-qualification and full tender process. This must be addressed if the widest range of providers are to play their full part in service provision. We recommend that all Local Authorities are required to use eProcurement so that tenders can be submitted electronically and that a single (online) pre-qualification process is implemented to avoid repeatedly providing the same information for different Authorities.

The Structure and Purpose of the Public Health Outcomes Framework

5. MEND strongly recommend that children’s indicators are included in the Public Health Outcomes Framework so that commissioners are not incentivised to prioritise adults over children in order to grow their budgets.

Arrangements for Funding Public Health Services

6. Steps should be taken to ensure that the ring fenced public health budget is translated to frontline public health services, and is not diverted into other areas such as social care. At the national level, MEND believes that the funding imbalance between prevention and treatment requires redressing.

7. Over the past 10 years we estimate that approximately £50 million has been spent on evidence-based treatment of child obesity, while £1.5 billion has been spent on preventative measures such as trying to improve nutrition, and increase levels of physical activity. While it is widely agreed that prevention is better than treatment, there is very little evidence to suggest that many of these preventative measures work. In contrast, there is considerable evidence to support targeted prevention and targeted treatment such as weight management programmes. These have a direct impact on slowing, and in due course reducing, the rate of growth of chronic diseases associated with obesity such as Type 2 Diabetes, cardiovascular disease, strokes and some cancers.

8. The ring fenced public health budget presents an opportunity to redress this imbalance. While both treatment and prevention are important, in the interests of “doing what works”, budget allocations should reflect a heavier focus on targeted prevention and treatment than has previously been the case.

9. The case for cost-effective evidence-based weight management programmes is far more compelling than that for many preventative measures. If the balance of spending is addressed, and some of the sums currently spent on primary prevention are reduced, then this rebalancing alone can save more than enough money to fund a long-term strategy for tackling obesity and any short-term interventions to address transition-related discontinuities—with far clearer outcomes than are currently visible. MEND is seeing increasing numbers of tenders for operating bundles of obesity prevention/wellness services, many of which appear to have a limited evidence base but are legacy services. A more rigorous case should be made for their continuation in the face of current funding pressures.

How the Government is Responding to the Marmot Review on Health Inequalities

10. MEND welcomes the government’s inclusion of five of the six recommendations made by the Marmot Review in Healthy People, Healthy Lives. In order for this to translate into practical action, these principles must be embedded in each area of public health policy. MEND hopes to see this emphasis in the Government’s forthcoming policy on obesity.

June 2011

Prepared 28th November 2011