Summary

Children’s wellbeing is strongly associated with parents’ physical and mental health, resources and parenting knowledge. The support needs of parents are dependent on many factors such as age, self-confidence, experience, personal circumstances etc. Support therefore needs to be sufficiently varied and flexible ranging from someone to listen to a concern, to universally available and timely advice, through to specialist support, targeted where there is greatest need. Support to parents includes a range of universally available services to which all parents are entitled, targeted services for parents who need specific support at particular times, and mandatory interventions for those parents who are unable to seek out or engage with existing support services.

Evidence-based parenting programmes are a means to help parents better understand the needs and behaviours of their child; supporting them to be the best parents they can be and equipping the whole family with tools that will enable them to build resilience, and lead healthy lives. In Merton, the targeted parenting offer includes a range of accredited programmes:

  • Incredible Years Baby/Toddler (6 weeks-2 years)
  • Incredible Years Pre-school (3-5years)
  • Incredible Years School Age (6-12 years)
  • Triple P ‘Stepping Stones’ Children with Disability (2-12years)
  • Strengthening Families Strengthening Communities (8-17years)
  • Domestic Abuse Programme
  • Caring Dads
  • Escape (8-17years).

Key commissioning implications

Commissioners need to:

  • recognise the integrated nature of lifestyle behaviour and wellbeing, continue to prioritise giving every child a healthy start in life and adopt place-based public health systems
  • ensure professionals are equipped to offer effective support to parents to support child wellbeing and resilience, and to provide targeted parenting programmes
  • work in partnership with schools to promote physical and emotional health and wellbeing, targeting schools in areas with high health needs.

Healthy weight in children

[The National Child Measure Programme (NCMP) results for 2012-13 show that] in Merton 9.0% of 5 year olds were classified as obese compared with 10.8% in London and 9.3% in England. This has reduced by 0.5% from 2011-12, and the overall trend is downwards from just over 12% in 2006-07. In Merton, 21.3% of 11 year olds were obese compared with 22.4% in London and 18.9% in England. This has increased by just under 1% from 2011-12, and the overall trend is upwards from just over 18% in 2006-07. There was a 12.3% difference in the level of obesity between 5 year olds and 11 year olds. This difference has increased by over 6% since 2006-07, when there was a gap of just over 6% in 2006-7. Looking at excess weight overall, over 21.2% (over 1 in 5) of 5 year olds are categorised as overweight or obese, rising to 35% (over one third) of 10-11 year olds. There was an increase of nearly 14% in excess weight between 5 year olds and 11 year olds. This has reduced by 2.8% for 5 year olds and increased by 0.9% for 11 year olds since 2006-07.

The significant increase in levels of obesity between 5 year olds and 11 year olds needs to be understood and action taken in schools, particularly in Years 3 and 4, and with communities and families, to start to reverse this trend. Information from the NCMP shows nationally that children from black and ethnic minority (BME) groups are more likely to be obese. In Merton, wards in the east of the borough have higher levels of obesity at ages 5 and 11 than those in the west.

Commissioning recommendations

  • Develop a sustainable, community-wide, multi-agency approach to increasing levels of healthy weight for children and young people and their families, which addresses inequalities by gender, ethnicity and area. Ensure that evidence from NICE on working with local communities to achieve healthy weight is implemented and that all local levers are being maximised, e.g. planning, parks and leisure, transport etc.
  • Ensure ongoing monitoring of the NCMP to inform targeting of resources in areas with children with higher levels of excess weight. Evidence on the increasing gap in obesity between 5 year olds and 11 year olds indicates the need to target children in school Years 3 and 4.
  • Review and maximise the capacity of School Nurses and delivery of preventative aspects of the Healthy Child Programme (5-19 years).
  • Recommission Weight Management services for children and young people, including an increased focus on prevention. Develop local obesity pathways for children and young people.
  • Pupils’ health and wellbeing have an impact on their educational performance. Effective preventative work in schools and wider communities needs to be done to mitigate health and lifestyle choices becoming a barrier to learning and attainment.
  • Ensure opportunities for promoting healthy lifestyles in schools and wider communities is maximised, particularly among schools in the east of the borough. Increase number of schools registered with the Healthy Schools London programme.

Dental health in children

The latest NHS Dental Survey of 5 year olds in 2011-12 showed that 29.2%, or 3 in 10, 5 year olds in Merton had decayed or missing teeth, compared with 27.9% for England and 32.9% for London. This is a 6.4% increase compared with 2008-09, when 22.8% of 5 year olds in Merton had decayed or missing teeth, which was lower than both England (30.9%) and London (32.7%).

In 2012, 13.1% of 5 year olds in Merton had tooth decay that had been filled, compared with 11.2% for England. This compares with 31% for Merton in 2008-09, which was the highest in the Care Index in London, and indicates a 17.9% reduction. This requires further investigation. Children from lower socioeconomic backgrounds are disproportionately affected.

Key commissioning recommendations

  • There is a need to improve access to NHS dental services for children and particularly in the early years.
  • There is a need to review progress on implementing the recommendations from the oral health promotion evaluation. These recommendations included:  
  • beginning health promotion interventions antenatally and targeting a wider range of at-risk populations
  • linking with other health promotion programmes, such as smoking cessation, alcohol-related and diet programmes
  • including evaluation as a key component of the service
  • delivering an oral health promotion programme at a wider geographical level e.g. across South West London.

 

Key facts about child wellbeing and resilience

Wellbeing is more than the absence of illness and is linked to physical health, health behaviours and resilience (ability to cope with adverse circumstances). Children’s wellbeing is strongly associated with neighbourhoods in which they live and by their parents’ resources, health, environment, housing conditions, social networks and parenting knowledge. Health behaviours also relate to individual wellbeing and recent research1 has confirmed the following associations:  

  • Screen time (including computer use for non-homework, watching television, DVDs and videos and time spent playing computer games) is negatively associated with young people’s wellbeing.
  • Physical activity is associated with lower levels of anxiety and depression, with children being happier with their appearance and reporting higher levels of self-esteem, happiness and satisfaction with their lives.
  • Healthy eating and diet: eating breakfast has a positive impact on short-term cognition and memory; family meal times appear to be important to wellbeing; in England of 11-15 year olds nearly 40% drink soft drinks at least once a day, just over 60% report eating breakfast and between a third and just under a half report eating fruit or vegetables every day.
  • A young people’s health is positively associated with their mother’s wellbeing; getting on well with siblings is associated with high levels of happiness and less worry; and having lots of friends at school is associated with happiness and wellbeing.

Parents' role in child wellbeing and resilience

Children’s wellbeing is strongly associated with parents’ physical and mental health, resources and parenting knowledge. The support needs of parents are dependent on many factors such as age, self-confidence, experience, personal circumstances etc. Support therefore needs to be sufficiently varied and flexible, ranging from someone to listen to a concern, to universally available and timely advice, through to specialist support, targeted where there is greatest need. Support to parents includes a range of universally available services to which all parents are entitled, targeted services for parents who need specific support at particular times, and mandatory interventions for those parents who are unable to seek out or engage with existing support services.

Parents are the most significant influence on children, so it is important that parents can access the support they need to parent effectively. Support may take the shape of antenatal care, postnatal care, support to tackle alcohol and substance misuse, support for specific vulnerable groups (such as teenage parents) or support at specific ages and stages (such as transition from primary to secondary school).  

Evidence-based parenting programmes are a means to help parents better understand the needs and behaviours of their child; supporting them to be the best parents they can be and equipping the whole family with tools that will enable them to build resilience, and lead healthy lives. In Merton the targeted parenting offer includes a range of accredited programmes e.g:

  • Incredible Years Baby/Toddler (6 weeks-2 years)
  • Incredible Years Pre-school (3-5yrs)
  • Incredible Years School Age (6-12 years)
  • Triple P ‘Stepping Stones’ Children with Disability (2-12yrs)
  • Strengthening Families Strengthening Communities (8-17yrs)
  • Domestic Abuse Programme
  • Caring Dads
  • Escape (8-17yrs).

Schools’ role in child wellbeing and resilience

Schools can be an important driver of resilience in children. They can provide children with learning opportunities and the competencies to develop a positive identity and healthy behaviours, as well as the skills to negotiate life’s challenges. However, school can also function as a risk to children’s health and wellbeing. Factors such as bullying and poor educational attainment can impact negatively on children’s mental health status.

For further details on access to education see Early Child Development and Education.

There are many evidence-based opportunities to promote health and wellbeing through schools, including personal, social, health and economic education (PSHE), and emotional learning in school; extra-curricular activities; positive classroom management; and links with family and wider community. School Nurses play an important role to support schools and pupils; and in Merton there are a number of services that provide support for young people in schools and colleges, including good sexual health promotion, advice on substance misuse, stop smoking support and weight management programmes Healthy Schools London is an awards programme that recognises schools’ achievements in improving pupil health and wellbeing across four areas: healthy eating; physical activity; PSHE; and emotional health and wellbeing.

Key commissioning implications

Commissioners need to:

  • recognise the integrated nature of lifestyle behaviour and wellbeing and to continue to prioritise giving every child a healthy start and to adopt place-based public health systems
  • ensure professionals are equipped to offer effective support to parents to support child wellbeing and resilience, and to provide targeted parenting programmes
  • work in partnership with schools to promote physical and emotional health and wellbeing, targeting schools in areas with high health needs.

Key facts about children achieving a healthy weight

Childhood obesity has been increasing over the past two to three decades worldwide but there was very little robust data to identify what the increase was on a local basis. In 2006 the NCMP was introduced to measure the height and weight of all children by the time they reached 5 and 11 years old (Reception and Year 6), year on year.

The NCMP results for 2012-13 show that coverage was at 93.5% for Reception and 96.4% for Year 6 pupils:

  • 9.0% of 5 year olds in Merton were classified as obese compared with 10.8% in London and 9.3% in England. This has reduced by 0.5% from 2011-12, and the overall trend is downwards from just over 12% in 2006-07.
  • 21.3% of 11 year olds in Merton were obese compared with 22.4% in London and 18.9% in England. This has increased by just under 1% from 2011-12, and the overall trend is upwards from just over 18% in 2006-07.
  • There was a 12.3% difference in the level of obesity between 5 year olds and 11 year olds. This difference has increased by over 6% since 2006-07, when there was a gap of just over 6% in 2006-07.  
  • Looking at excess weight overall, over 21.2% (over 1 in 5) of 5 year olds were categorised as overweight or obese, rising to 35% (over 1 third) of 10-11 year olds. There was an increase of nearly 14% in excess weight between 5 year olds and 11 year olds. This has reduced by 2.8% for 5 year olds and increased by 0.9% for 11 year olds since 2006-07.

The significant increase in levels of obesity between 5 year olds and 11 year olds needs to be understood and action taken in schools, particularly in Years 3 and 4, and with communities and families, to start to reverse this trend.

Excess weight (overweight and obesity) in children in Reception Year, 2011-12.

 

 

Excess weight (overweight and obesity) in children in Year 6, 2011-12.

 

 

Trends in excess weight in children in Reception Year, 2006-07 to 2011-12.

Trends in excess weight in children in Year 6, 2006-07 to 2011-12.

 

 

Variation by gender: Information from the NCMP shows that, in Merton, boys are more likely to be obese that girls, particularly at age 11, where the prevalence of obesity is 6% higher among boys than girls.

 

Prevalence of obesity in children by gender.

 

Variation by ethnicity: Information from the NCMP shows nationally that children from BME groups are more likely to be obese. Nationally 2012-13 data shows that at age 5 years prevalence of obesity was 8.6% for white groups; 10.3% for Asian or Asian-British groups; and 15.5% for black or black-British groups. At age 11 years prevalence of obesity was 17.6% for white groups; 20.3% for Asian or Asian-British groups; and 27.1% for black or black-British groups.

Variation by area: It is clear that the levels of children who are overweight or obese are significant and that the levels of overweight and obesity increase as children get older. Information locally confirms there is a link to deprivation, so that children of poorer households have a greater risk of being overweight or obese and are therefore at greater risk of certain diseases. In Merton, wards in the east of the borough have higher levels of obesity at ages 5 and 11 than those in the west.

Prevalence of obesity in children in Reception year by ward in Merton.

Prevalence of obesity in children in Year 6 by ward in Merton.

Physical activity: The Chief Medical Officer’s guidelines for physical activity ‘Start Active, Stay Active’ (2011) have a focus on being active every day and set out the recommended minimum levels of activity for children and young people in order to achieve health benefits:

  • Under 5 years old: 180 minutes – three hours daily, spread throughout the day, once a child is able to walk.
  • Children and young people (5-18 year olds): 60 minutes and up to several hours every day of moderate to vigorous intensity physical activity. Three days a week should include vigorous intensity activities that strengthen muscle and bone.

The most recent data available shows that 58% of children in Merton took part in three hours of physical activity or sport per week, higher than the regional or national averages (2009-10). No data is available for pre-school age children.

Key facts about services to promote healthy weight

There is no simple solution to the challenge of reducing obesity. It is important that integrated and wide-ranging approaches involving national and local action should be adopted to help tackle the growing problem. Tackling obesity requires a multi-agency response across the life course, including whole family approaches, promoting healthy food choices, building physical activity into our day to day lives, providing safe open spaces, promoting walking and cycling, promoting the role of employers and business and providing personalised advice and support to individuals.

The role of the local workforce in addressing healthy weight is crucial and includes promotion of healthy weight in pregnancy, promotion of breastfeeding, physical activity and healthy eating activity in children’s centres, schools, health services and community settings, weight management support, and work with fast food businesses through a local ‘Responsibility Deal’.

The national Healthy Child Programmes (Pregnancy and the first five years of life and From 5-19years)2 set out the recommended framework of universal and progressive services for infants, children and young people to promote optimal health and wellbeing, bringing together a wide range of programmes and interventions. They recommend how health, education and other partners working together across a range of settings can significantly enhance a child or young person’s life chances. Promoting healthy weight is one of a range of priorities within the programmes. The School Nursing Service delivers the NCMP and has an important role in promoting and supporting healthy weight among children and parents.

Merton has a targeted service for child weight management which aims to support and empower parents and children from 4-19 years old to adopt healthy eating practices, increase physical activity levels, reduce sedentary behaviour and build self-esteem. A secondary aim is to contribute towards children improving their long-term health through achieving and maintaining a healthy body weight. The 12-week programme is aimed at children in Merton aged between 4 and 19 years who are overweight, plus their families. There is an education and behavioural change component to each session with the children taking part in at least 40 minutes of physical activity per session. Between July 2012 and July 2013, 91 families from Merton completed the programme. An extended training programme for professionals also provides advice on how to raise the issue of weight and provide general advice on appropriate lifestyle changes.

What works to help people to achieve a healthy weight?

NICE has published guidance on evidence-based approaches to enabling communities and specific at-risk groups achieve a healthy weight.

Guidance on working with local communities to achieve a healthy weight (NICE 2012) recommends to:

  • develop a coherent sustainable, community-wide, multi-agency approach
  • align action to tackle obesity with other disease specific prevention and health improvement strategies, such as for CHD and diabetes
  • ensure strategic leadership and support at all levels
  • ensure coordinated local action and communication in public health teams, local business and social enterprises, voluntary and community organisations
  • train and develop all partners, professionals and those in local services
  • develop a communication strategy through appropriate branding, language and advocacy
  • monitor and evaluate cost-effectiveness
  • embed scrutiny and accountability.

For relevant information see Obesity: working with local communities (NICE website)

Guidance on walking and cycling (NICE 2010) recommends:

  • developing a local strategy and policy support for walking and cycling networks and infrastructure
  • developing road safety partnerships and strategies
  • addressing motor traffic speeds and introducing engineering measures
  • ensuring all relevant planning consider walking and cycling
  • developing cross sector walking and cycling programmes
  • commissioning personalised travel planning
  • developing community-wide walking programmes, including for older people and providing individual support
  • developing cycling programmes.

For relevant information see Walking and cycling (NICE website)

Guidance on managing overweight and obesity among children and young people (NICE 2013) recommends:

  • Action on planning, commissioning and delivery to ensure that family-based, multi-component lifestyle weight management services for children and young people are available as part of a community-wide multi-agency approach to healthy weight and prevention and management of obesity.
  • The core elements of services to be provided as part of a locally agreed obesity care or weight management pathway.

Commissioning implications for supporting children and young people to achieve a healthy weight

Tackling obesity and helping people achieve a healthy weight are key to preventing future illness. With an increasing population and rising numbers of people projected to live longer, helping to prevent future ill health, such as diabetes, cancer and heart disease, is vitally important if health and social care services are going to be able to cope in the future. It is important that an integrated and wide-ranging programme of solutions involving national and local action is implemented.

Tackling obesity requires a multi-agency response across all ages, including whole family approaches, promoting healthy food choices, building physical activity into our day-to-day lives, providing safe open spaces, promoting walking and cycling, promoting the role of employers, and providing personalised advice and support to individuals. As the lead organisation for public health and health improvement since April 2013, Merton Council is well placed to address these areas across all council policies, including planning, housing, leisure services and social care.

Health services have a vital role to play in providing support and care. Consistent messages from health and other professionals about healthy weight and physical activity are essential and training and support are needed. How messages on achieving and maintaining a healthy weight are presented are key to support behaviour change. Commissioners need to ensure that positive messages are presented, and that any interventions are fun (not overtly health oriented) and locally available, with local champions to support healthy choices.

Commissioning recommendations:

  • Develop a sustainable, community-wide, multi-agency approach to increasing levels of healthy weight for children and young people and their families, which addresses inequalities by gender, ethnicity and area. Ensure that evidence from NICE on working with local communities to achieve healthy weight is implemented and that all local levers are being maximised, e.g. planning, parks and leisure, transport etc.
  • Ensure ongoing monitoring of the NCMP to inform targeting of resources in areas with children with higher levels of excess weight. Evidence on the increasing gap in obesity between 5 year olds and 11 year olds indicates the need to target children in school Years 3 and 4.
  • Review and maximise capacity of School Nurses and delivery of preventative aspects of the Healthy Child Programme (5-19 years).
  • Recommission Weight Management services for children and young people, including an increased focus on prevention. Develop local obesity pathways for children and young people.
  • Pupils’ health and wellbeing have an impact on their educational performance. Effective preventative work in schools and wider communities needs to be done to mitigate health and lifestyle choices becoming a barrier to learning and attainment.
  • Ensure opportunities for promoting healthy lifestyles in schools and wider communities is maximised, particularly among schools in the east of the borough. Increase the number of schools registered with the Healthy Schools London programme.

Key facts on dental health of children

Oral health is a key measure of inequality. Children, particularly those in deprived areas, tend to have poorer oral health, which can lead to or be predictive of other conditions. Tooth decay is predominantly preventable, however, significant levels remain (nationally, 28% of 5 year old children have observable decay) resulting in pain, sleep loss, time off school and, in some cases, treatment under general anaesthetic.

The Public Health Outcomes Framework includes ‘tooth decay at 5 years’ as an indicator to encourage local authorities to focus on oral health improvement initiatives to reduce levels of decay. This indicator measures the average severity of tooth decay per child based on the NHS Dental Survey. In Merton in 2012 it was estimated that the average number of teeth per child aged 5 years which had decay was 0.92, which was better than London (1.23), and similar to England (0.94).

NHS Dental Survey

The NHS Dental Epidemiology Programme for England (NHS DEP)3 2011-12, an oral health survey of 5 year old children, gives estimates for disease prevalence and severity reported at national, regional and local authority levels. Overall, 27.9% of 5 year old children in England whose parents gave consent for participation in this survey had experienced dental decay. On average these children had 3.38 teeth that were decayed, missing or filled (at age 5, children normally have 20 primary teeth). The average number of decayed, missing or filled teeth in the whole sample (including the 72.1% who were decay free) was 0.94.

At regional and local authority levels, the results revealed wide variation in the prevalence and severity of dental decay; the areas with poorer oral health tend to be in the north and in the more deprived local authorities. Findings from the NHS DEP estimate that in Merton 29.2% of 5 year olds had tooth decay, which was better than London (32.9%) and similar to England (27.9%)

The survey also estimates the proportion of decayed teeth filled by dentists (Care Index), which reflects the extent of restorative care to teeth in need of this. In 2012,

Trends in oral health

The methodology used in the 2012 survey enables comparisons with a previous survey in 2008. Nationally the results show a reduction in the proportion of children with dental decay from 30.9% in 2008 to 27.9% in 2012. Reductions in severity were also evident, with the average number of decayed, missing or filled teeth falling from 1.11 in 2008 to 0.94 in 2012.

Trends in the Care Index estimate that the proportion of decayed teeth filled by dentists in Merton reduced from 24.4% in 2008 to 13.1% in 2012. This is a reduction of 11.3%; however, again, this must be treated with caution as the sample size at local level is small. At a regional level, the proportion of decayed teeth filled by dentist increased from 12.1% in 2008 to 13% in 2012.

The Care Index shows considerable variation within regions and in London the range in 2012 was from 6.2% in Havering to 29.5% in Kingston. The Care Index should be interpreted alongside other intelligence, such as deprivation, disease prevalence and the provision of dental services.

 

Key facts on services for dental health

Access to NHS Dentistry

Everyone should be able to access good quality NHS dental services. Dental care is provided by dental practitioners across Merton.

In terms of the number of people accessing NHS Dentistry, currently data is only available for Sutton and Merton combined. However, based on this 62.3% of children in Merton accessed NHS dentistry in 2013, indicating that nearly 38% of children do not access NHS Dentistry. This is similar to London but lower than national averages. Compared with 2006, the uptake of NHS Dentistry in Sutton and Merton has remained the same for adults but has reduced by 5.4% for children.

NHS dental patients as a percentage of the population, 2005-06 and 2012-13.

Services to promote dental health

The Oral Health Promotion Service is provided by the Sutton and Merton Community Dental Services. Health promotion professionals provide training, advice and direct promotion to:

  • Children’s Centres (targeting parents of children aged under 5 years)
  • Health visitors (targeting parents of children aged under 5 years)
  • Primary schools (targeting children aged 3-12 years)
  • Supported living institutions (targeting adults with learning disabilities)

In 2011, an evaluation of dental health promotion4 was carried out to describe the current Oral Health Promotion Service in Sutton and Merton and make recommendations for the service. This identified that the service was meeting a range of quality standards and identified opportunities for further development

 

Key commissioning recommendations

  • There is a need to improve access to NHS dental services for children and particularly in the early years.
  • There is a need to review progress on implementing the recommendations from the oral health promotion evaluation, ensuring that they are implemented effectively. These recommendations included:
  • beginning health promotion interventions antenatally and targeting a wider range of at-risk populations
  • linking with other health promotion programmes, such as smoking cessation, alcohol-related and diet programmes
  • including evaluation as a key component of the service
  • delivery of oral health promotion at a wider geographical level e.g. across South West London.

References

1.^ Public Health England (2013). How healthy behaviour supports children’s wellbeing. Public Health England Briefing, PHE Publications: 2013146.

2.^ DH (2009), Healthy Child Programme: Pregnancy and the First Five Years; DH (2009) Healthy Child Programme: From 5-19 years...

3. ^2011-12 Survey Results of 5 Year Old Children (2012). NHS Dental Epidemiology Programme .

4.^ Exall, S. (2011).  An Evaluation of the Oral Health Promotion Service. NHS Sutton and Merton.