Tam Fry highlights the need for indicators to monitor and manage overweight and obesity in pre-school children appropriately

Are we now to have local quality and outcome frameworks (QOF)? This proposal, published by the Department of Health (DH) in September in its Next Stage Review Newsletter,1 would allow PCTs to make their choice of indicator from a national ‘menu’. This idea has both champions and adversaries, but the National Obesity Forum (NOF) is preparing to welcome the motion even before the debate is over. The NOF is the GP-led body trying to persuade the DH to put obesity at the top of its QOF agenda, and, given that the areas with a high prevalence of obesity are well charted, believes that introduction of local QOFs would be a welcome move and are urgently required.

Local QOFs

The NOF is certain that it is pushing at an open door. It was convinced of this by remarks made by the Health Secretary, Alan Johnson, following his July address to the Fabian Society. In his speech, he made a plea for not only families, but employers, retailers, the leisure industry, the media, local government, and the voluntary sector to help the DH in reducing the nation’s weight. In the subsequent question and answer session, he also added that the role of QOFs would be significant.

The NOF is counting on a successful outcome to the British Medical Association (BMA) and DH negotiations on the QOF for 2009/2010, and trusts that the strategy will remain should there be a change in government.

Earlier monitoring and intervention

The growing prevalence of obesity in childhood needs to be countered earlier rather than later. The NOF believes that monitoring individuals after the age of 16 years is far too late to be truly effective, and QOF indicators need to be introduced during the pre-school years (1–4 years of age). In addition, the group insists that the indicators must be more than registers; compiling lists of overweight children without providing an incentive for changing their behaviour is of little use. The QOF should be targeted at those early years when interventions have more than a reasonable chance of success.

The NOF is of the opinion that yearly body mass index assessment should be initiated from the age of 1 year and that local or national QOFs could help to ensure that this is achieved. The Chief Medical Officer for England called for GPs, practice nurses, and health visitors to identify and intervene at the earliest signs of obesity as long ago as 2003.2 A year earlier, the Royal College of Paediatrics and Child Health had urged that every child with severe or progressive obesity should be referred to a paediatrician before the age of 2 years.3 However, no action was taken in response to either of these calls.

Grave concerns have been expressed by the NOF over statistics from the National Child Measurement Programme (NCMP), which show 22.6% of UK children entering primary school are either overweight or obese.4 The NOF considers pre-school surveillance is long overdue. The Government has repackaged its ‘target’ of halting the year-on-year rise in obesity in children under 11 years of age by 2010 to the ‘ambition’ of reducing overweight and obesity in children to 2000 levels by 2020,5,6 and the NOF considers that based on present performance, not even this ambition will be met.

Recording overweight and obesity in children

The current school-based NCMP4 is aimed at informing local planning and delivery of services for children, and at gathering population-level surveillance data to allow analysis of trends in growth patterns and obesity. It therefore does not address the needs of an individual child.

Before the programme started, PCTs wrote to the parents and carers of all children eligible for measurement to inform them of the work, and to provide them with the opportunity to opt their children out; children were not forced to participate if they did not want to. For 2006/07, 80% (876,416) of all eligible pupils from Reception class (aged 4–5 years) and Year 6 (aged 10–11 years) were measured.4 If the NCMP data are to be used as an indicator of childhood obesity, there may be additional pressure to obtain 100% coverage.

Obesity in adults

In terms of managing adult obesity, the Health and Audit Commission’s report, Are we choosing health?, announced in July that the QOF indicator for obesity (see Table 1) was being dropped as a public health indicator.7 In response to the removal of this public health marker, the Commission stated that the move had ‘the potential to reduce the focus on obesity in adults in primary care.’ The NOF agrees, and it is amazed that data from the OB 1 indicator are no longer considered a ‘vital sign’ of the nation’s health.

Removal of the OB 1 indicator from the QOF would mean that the watchdogs would have no data to analyse for the assessment of adult obesity.

Table 1: Clinical indecation for obesity

No. Indicator Points Payment stages
OB 1 The practice can produce a register of patients aged 16 years and over with a BMI ?30 in the previous 15 month 8  

Future guidance

Although it may be some time before the BMA/DH negotiations regarding local QOF indicators are concluded, a further pointer may emerge later this autumn. Clinical indicators may appear in a child health strategy that is scheduled for publication by the Department for Children, Schools and Families. It is to be hoped this document will provide clearer guidance for healthcare professionals on child obesity.8

  1. Department of Health. NHS Next Stage Review: Our vision for primary and community care. Newsletter—September 2008. London: Primary and Community Care Strategy Team, 2008.
  2. Department of Health, Chief Medical Officer. Annual Report of the Chief Medical Officer 2002. London: DH, 2003.
  3. Royal College of Paediatrics and Child Health & National Obesity Forum. An approach to weight management in children and adolescents (2–18 years) in primary care. Nottingham: NOF, 2002.
  4. The National Child Measurement Programme www.ncmp.ic.nhs.uk/
  5. Department of Health. Spending Review 2004 Public Service Agreement. www.dh.gov.uk/en/Aboutus/HowDHworks/Servicestandardsandcommitments/DHPublicServiceAgreement/DH_4106188
  6. Department of Health. Healthy Weight, Healthy Lives: a Cross Government Strategy for England. London: DH, 2008.
  7. Healthcare Commission, Audit Commission. Are we choosing health? The impact of policy on the delivery of health improvement programmes and services. London: Commission for Healthcare Audit and Inspection, 2008.
  8. Department of Health. Updated Health Promotion Programme—Pregnancy and the first five years of life. London: DH, 2008.G