27 Nov 2020
The British Dietetic Association is the professional body and trade union representing the dietetic profession in the UK. One of the oldest and most experienced nutrition bodies in the world, the Association was founded in 1936.
Dietitians are the only legally regulated nutrition specialist health professionals in the UK. They work in a wide range of roles, including NHS, public health, care sector, academia, sports and media.
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 and wider food strategy, preventing people from developing obesity and poor diet in the first place or catching issues 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 2019/20 than in 2016/17[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].
Obesity and other diet related conditions such as type 2 diabetes are long-term conditions, and our attempts to bring down obesity rates and improve the nation’s health will take years if not decades. Therefore, local government needs long term, multi-year budgets to help plan weight management services and public health nutrition strategies in the long term. Another one-year settlement does not deliver this. It is also important that the services that are invested in are themselves long-term in their focus. Obesity is a long-term, chronic condition that will require long term practical support. Twelve-week interventions are not enough.
One of the main benefits of a local approach is that public health services can be tailored to the specifics of local need. Diet and nutrition related conditions impact at different rates in different parts of the country, and the appropriate solutions and interventions will differ depending upon demographics and other factors. Therefore, it is important that local Directors of Public Health have the flexibility to access funding and resources to deliver services as they need them.
When we fail to support and fund public health services, we instead pick up the costs and consequences later down the line, at increased cost, within the NHS. Dietitians see the long-term consequences of poor diet and nutrition every day, and know how much more difficult it is to treat or manage later in life.
We believe central government must provide support to local government to enable:
- Significant investment in 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.
- Investment in long-term weight management and obesity prevention services.
- Expansion of existing evidence-based programmes for children and families, such as Planet-Munch[v], LEAF[vi] and others.
- Funding 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]).
- Public health budgets to be brought up to 2015/16 levels as a minimum.
- Multi-year settlements for public health budgets to help local services plan and target over the long term through integrated commissioning.
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].
Malnutrition incurs significant costs to public services, lengthening hospital stays, increasing risk of falls and placing additional strain on the care sector. COVID-19 will have made malnutrition worse, and individuals and the country as a whole will be slower to recover if they are not getting the nutrition and hydration that they need. Treating the end results of malnutrition in the acute sector is a much more expensive way of dealing with the issue than treating it in the community or preventing it in the first place.
We believe central government must:
- Invest in social care services to ensure that everyone is screened for malnutrition in the community and in care homes. This will involve in particular investment in staff training.
- Provide 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.