24 Sep 2020
About the BDA
The British Dietetic Association (BDA) is the professional body and trade union representing the professional, educational, public and workplace interests of UK dietitians. Founded in 1936, we are one of the oldest and most experienced dietetic organisations in the world. Dietitians are highly qualified health professionals, legally regulate by the Health and Care Professions Council. They assess, diagnose and treat dietary and nutritional problems at an individual and wider public-health level.
Local Authorities play an absolutely vital role in the delivery of public health and prevention services within England, including weight management and nutrition services. These services should form a key part of the government’s obesity strategy, preventing people from developing obesity in the first place or catching children and adults early, before further health problems develop. However, we know that public health has been impacted by the significant reductions in local authority funding over the past decade, and services targeting adult and child obesity are no exception.
The public health grant to local authorities was £850 million lower in real terms in 2016/17 than in 2019/20[i]. The increases to that allocation in 2020/21 go only a small way to refilling that gap. The Health Foundation estimates that £0.9 billion investment is needed to return public health funding to 2015/16 levels next year[ii].
According to Local authority outturns[iii], budgeted spending on obesity services for both adults and children has dropped in cash terms by £2.9 million and £1.2 million between 2016/17 and 2020/21, even with increases in the overall public health allocation in 2020/21. In roughly calculated real terms, this is a £13.8 million shortfall. The NAO have reported with regards to childhood obesity funding (including the NSMP), “at £61.7 million out of public health expenditure of £3.4 billion, it is one of the lowest areas of public health spend by local authorities”[iv].
- Investing significantly more in local authority adult and child obesity services to at least bring spending up to 2016/17 levels in real terms, approximately £13.8 million across local authorities in England.
- Fund the expansion of existing evidence-based programmes for children and families, such as Planet-Munch[v], LEAF[vi] and others.
- Ensuring that services are funded so that local authorities and NHS services can meet NICE recommendations for the provision of lifestyle weight management services for adults and children (PH47[vii] and PH53[viii]).
- At a wider level increasing the public health budgets to bring them up to 2015/16 levels.
Alongside from those tiers 1 and 2 weight management and wider public health services delivered by local authorities, we need to invest in weight management and support services across the life course – in the NHS, in education and the community. This should include specialist tier 3 services for all ages, and a significant expansion of access to tier 4 bariatric surgery for those whose health is most impacted by overweight or obesity.
The government has also promised investment in NHS digital weight management services and to accelerate the NHS Diabetes Prevention Programme. This is a good start, but we need to go further. The proposed digital offer needs to be funded as well as, and not instead of local authority weight management services. They need to be available to wider range of patients than currently recommended and they need to be for longer than 12 weeks. Obesity is a chronic condition that requires long term support. Our recent response to the NHSE/I discussion paper has more detail[i].
At the moment too few children, adults or families have access to appropriate specialised support, and access to services has become a “postcode lottery”. NICE quality standards state that services providers in primary, community and secondary care should “ensure that they have a choice of interventions available for people for whom tier 2 services have been unsuccessful. This includes agreed pathways for referral to tier 3 services, or equivalent.10”
- Invest in further research into effective weight management services across the whole life-course, from pre-conception to adulthood and old age.
- Expand highly specialist tier 3 weight management services so everyone who should be referred to one can be, at all ages. This is in line with NICE quality standards[ii].
- Expand availability of tier 4 bariatric surgery and related support. Currently, only approximately 5,000 people per annum are able to access such surgery, the British Obesity and Metabolic Surgery Society (BOMSS recommend this should be doubled, which would still only be 0.4% of those eligible[iii].)
Obesity and related conditions such as type 2 diabetes are the single biggest cost to health services in the UK. It also disproportionately impacts the least well off in society, with children and adults in the lowest economic deciles much more likely to have obesity.
The food we are provided in hospitals is vital to patients’ treatment and recovery. Without good quality, nutritious food, recovery times are slowed, and patients risk developing malnutrition. It is not simply good enough to ensure that food contains all the necessary nutrients, it must be appetising and patient must have the necessary support to consume it.
As catering/food provision is not currently a ring-fenced aspect of hospital budgets, it is often amongst the first areas to be frozen or cut back when trusts face financial pressures. This is compounded by catering’s classification as a part of “estates” rather than being regarded as a key part of treatment and recovery.
Further investment in NHS Catering will achieve the government’s aim of improving public services, reducing burdens on the NHS from malnutrition and bolster the UK’s vital catering industry, which has been hit hard by the COVID-19 crisis.
We recommend acting quickly upon the recommendations of the forthcoming Independent Hospital Food Review[i], as well as;
- Providing ring-fenced funding to every NHS hospital for catering to significantly increase the average spend per head on food.
- Providing capital funding to hospitals, determined by need, to upgrade catering facilities, eating areas and on-ward preparation areas.
- Providing funding for staff to assist with eating and drinking, and ensure unsafe or unused food is rapidly removed.
- Providing funding for every hospital or trust to have access to a specialist catering dietitian. This is estimated to cost around £4 million per annum. Fuller figures will appear in the Independent Hospital Food Review.
Malnutrition (taken to mean under-nutrition) is a significant issue that rarely receives the same degree of attention as obesity as a public health concern. Malnutrition impacts millions of people a year, in particular the elderly. It is estimated that one in ten over 65s is malnourished or at risk of being so. The cost of malnutrition in England alone was estimated to be £19.6 billion per year in 2011/12, or more than 15% of the total public expenditure on health and social care[i]. COVID-19 will have increased the risk of malnutrition, especially amongst those forced to shield.
There are multiples potential causes, from diseases such as cancer to mental ill health, physical disability, isolation or lack of support. Unfortunately, the vast majority of malnutrition goes undiagnosed and is not picked up until someone enters to care system or is admitted to hospital, and even then, that is not guaranteed. It is estimated that 96% of malnutrition cases are in the community.
COVID-19 illustrated what the government could do to address malnutrition (and food insecurity, see below) with The Local Authority Emergency Assistance Grant for Food and Essential Supplies and Coronavirus Community Support Fund. We need this sort of investment to continue, to reverse the demise of services that support people to eat such as Meals on Wheels, where recent analysis showed half of councils no longer provided[ii]. We also need further investment in integrated, dietetic led community services which can identify and support people at risk of malnutrition[iii].
- Investing in health and social care services to ensure that everyone is screened for malnutrition in the community, in care homes and in hospital. This will involve in particular investment in staff training.
- Invest in community dietetic and nutrition teams as part of an integrated approach to identifying and supporting the vast majority of people at risk of malnutrition living in the community.
- Providing funding to reverse cuts to community food services such as Meals and Wheels. This can in part be addressed by plugging the significant gap in public health funding mentioned above.
The COVID-19 pandemic has highlighted and worsened the level of food insecurity within the UK. Prior to the pandemic, it was estimated by the UN Food and Agriculture Organisation’s (FAO) Food Insecurity Experience Scale (FIES) that 2.4 million people are experiencing “severe” food insecurity, defined as occasionally going a whole day without eating[i].
A fundamental reason for this insecurity is a lack of money. It is difficult for people with little financial security to consume a healthy diet. Broken Plate, a 2019 report by the Food Foundation, found the poorest 10% of UK households would need to spend 74% of their disposable income on food to meet the recommendations made in PHE’s Eatwell Guide[ii].
- Invest further in social welfare to ensure that payments are sufficient that nobody in receipt of benefits is forced into food insecurity. Ensure that Universal Credit is fit for purpose and no sanctions or processing delays force someone to choose between eating or paying rent.
- Consider specific action to ensure food remains affordable, in particular the food necessary to consume a healthy diet as recommended by the Eatwell Guide.
- Provide the funding necessary to implement a legally enshrined “Right to Food[iii]” that requires central government, local authorities and public services to take specific action to address causes of food insecurity and prevent hunger.
Such food insecurity has a negative impact on health, reduces life chances for children and increases reliance on crisis services. If the government’s aim of “levelling up” is to mean anything, it must start with ensuring nobody in our wealthy country is going hungry.
Healthy Start is an important means-tested scheme providing a basic nutritional safety net to lower income and more vulnerable families, supporting them to make healthy food choices. We want the government to build on its success so more children and families benefit from a better start in life.
Unfortunately, uptake of the scheme remains too low, with less than half of all those eligible benefiting from the scheme across England, and uptake as low as 43.5% in the East of England[i]. This is in part due to the difficulty of accessing the scheme, which still requires that applicants print off and mail an application form.
The value of the Healthy Start voucher has not increased since 2009, and is currently £3.10. This has not taken account of inflationary increases in the price of food for over a decade. In cash terms, vegetable and fruit costs have increased significantly since 2009[ii].
The National Food Strategy Part [iii]1 estimated that extending the scheme to all pregnant women and all households with children under four who are in receipt of Universal Credit would increase eligibility to one million women and children. It estimates that this expansion and increasing the value of the vouchers would cost £110 million.
- Increasing the value of Healthy Start vouchers to at least £4.25. Government may wish to consider increasing this further.
- Extend Healthy Start to all households with children under four in receipt in Universal Credit.
- Providing specific funding to allow local health services to promote the Healthy Start scheme more widely to increase uptake.
- Investing in a more modern application process for Healthy Start vouchers, so that families are able to apply for and receive vouchers online.
Ensuring good nutrition, especially to young children, is vital for their development and attainment in later life. Updating and reinforcing the Healthy Start Scheme is a key way in which the Government can deliver against its “levelling up” agenda, and reduce impact on public services which have to deal with the consequences of poor nutrition later in a child’s life.
The SDIL has been a huge success in driving reformulation and reducing the total amount of free sugars consumed by children and adults. However, loopholes remain that allow high-sugar milkshakes to avoid the tax, and there are discrepancies between the SDIL and recommendations made under the Nutrient Profile Model (NPM), which is used to determine healthier and less healthy foods and beverages.
A typical 330ml can of orange Fanta still contains well over half of a child’s daily recommended sugar intake, but is not subject to the SDIL. However, a drink with 4.5g of sugar per 100ml would be classed as ‘less healthy’ by the NPM, yet not be subject to the SDIL. Aligning the SDIL with the NPM would increase policy coherence and incentivise drinks manufacturers to further reduce sugar from their products, or raise additional revenue.
Funding from the SDIL is currently invested in programmes including primary physical education. While this is laudable, evidence is clear that diet, not exercise, is a primary driver or excess weight. We would therefore recommend that future SDIL revenue is invested in diet-related programmes which are focused on increasing food skill and supporting healthy weight through diet.
- Lowering the threshold to 4.5g of sugar per 100g for all drinks
- Including milky drinks with added sugar in the same way as soft drinks, with a standardised allowance for intrinsic milk sugars.
- Committing to investing SDIL income in diet-related interventions for children.
Obesity has a significant impact, both in terms of resourcing and funds, on the NHS, and action such as the SDIL can help deliver the government’s aim of improving public services.