Healthy weight - local health systems support for pregnant women and young children: research

5. Consistency and coherence

This chapter considers the extent to which child healthy weight systems were consistently implemented, the factors that made consistency more or less likely, and the level of coherence across key transition points.

Consistency of implementation

The dominant perspective was that, overall, levels of consistency were fairly high. However, there was recognition that it was very difficult to establish consistency – levels of auditing and monitoring varied across health boards but were not, on the whole, systematic or comprehensive. Furthermore, professionals with clinical caseloads only knew what they and their immediate team did (and even then, only if there had been low staff turnover).

In relation to consistency of referrals, for example, there was a slight disconnect between public health professionals (who perceived greater inconsistency) and clinical employees (who perceived greater consistency). This could mean that the research sample (which was voluntary and opt-in, as discussed in Chapter 1) was skewed towards those who were more confident that they were following referral pathways correctly. It could also be the case that the perception of public health staff was not accurate – as mentioned, it was very challenging for any individual to know exactly how consistently processes are followed on the ground when there is little regular monitoring of referral patterns, for example.

Prevention

In relation to preventative advice, participants were confident that consistency was high and that parents were not being provided with conflicting advice. Consistent, clear national guidelines made it easier for health professionals to give the same advice. For example, participants were very comfortable implementing the guidance that weaning should happen at six months. They were less comfortable (and therefore likely less consistent) advising on how to manage weight during pregnancy, as they felt they did not have clear national guidance.

Where health professionals had a particular interest in child healthy weight, they may go above and beyond what their colleagues with other interests would do, thus introducing some level of inconsistency of support.

I think you can put as much or as little into that as you wish, depending on your passion. You know, I am extremely passionate about feeding, so that's my focus. So, if somebody was extremely passionate about weight or about drugs or about smoking, you know, then you tend to find you put more in.

Midwife

Those who had existing relationships with relevant colleagues (public health employees, dieticians, dental teams, GPs and so on) were also more able to seek professional advice and support, again giving rise to inconsistency in support. This is illustrated by the two contrasting quotes below, from health visitors in the same health board.

All the time I've worked in [health board], I know there's dieticians in [health board], but I've never met them, I don't know the names of them. They don't seem to have a part to play in our world of healthy eating for children – it just seems to be an adult based thing.

Health visitor

We would refer to dietician for advice even – we might not actually see them, but we would speak to them for advice. And usually, we've got such good links with the paediatric dieticians that they'll contact the families. It's excellent, they're a really good service that we have here.

Health visitor

In relation to breastfeeding advice specifically, the UNICEF 'Baby Friendly Initiative' was mentioned repeatedly by midwives and public health professionals, as it offers standards of best practice helping with consistency of breastfeeding support.

Identification and referral

Turning to consistency of weighing, the UHVP meant that every child was weighed and measured at the same point. This in itself facilitates greater consistency, but also enables more consistent opportunities for a weight issue to be identified and addressed.

There was consensus that, where clear referral pathways existed, they were consistently followed. As discussed in previous chapters, health professionals were confident in weighing and measuring, and assessing weight against BMI or centile-based referral thresholds, although there was a level of inconsistency in whether they used BMI centiles, weight or weight and height centiles. Where referral pathways were 'woollier' or relied more on professional judgment, inconsistency was perceived to be higher. Professionals also drew on the advice of their colleagues to ensure they were suggesting the most appropriate referral option.

One factor that facilitated greater consistency of referral was simply having somewhere to refer to: an established child healthy weight service which broadly met the Standards. There was less consistency in areas without a dedicated tier 2 service as those identifying weight issues may have different levels of awareness of other types of support (such as third sector groups), different levels of confidence initiating their own interventions, or may not raise the issue at all if they did not feel they had anything positive to offer families.

Other barriers to consistency

Across the strands of child healthy weight, there were other factors which made consistency harder to achieve. These included:

• Size of health board – there was a view that it was more difficult to achieve in very large health boards.
• Rurality – the more remote areas were generally less well-served by interventions.
• COVID-19 – had disrupted service provision in a number of ways, with some services moving to online programmes and others not running. In relation to health visiting provision, it had introduced inconsistency in the way visits were undertaken. For example, those who were shielding may have completed all their visits by phone (or 'Near Me' if available), while others continued to visit families face-to-face.
• Having a skills mix (for example nursery nurses undertaking 27-30 month checks) – this meant a greater range of professionals with different skills and training involved in weighing, identifying, and referring, which risked greater inconsistency.
• High caseloads – changes in workload week-to-week, as child protection issues for example arose, meant that the level of focus professionals were able to give weight issues varied.

Coherence across transition points

The literature states that intervention at each stage (preconception, pregnancy, infant feeding/breastfeeding, weaning, toddlerhood) tends to have only a small effect, and that achieving a substantial impact in obesity prevention requires the additive effect of interventions across multiple life stages in the early years^[51]. Furthermore, both Scottish Intercollegiate Guidelines Network (SIGN) Guidelines^[52] and the Standards recommend monitoring of progress in weight (adults) and BMI centiles (children). To do so requires enough time to see patients and families multiple times and/or for a family identified by one part of the system to be handed over comprehensively to the next (e.g., from health visitor to school nurse).

On the whole, however, boards did not have coherent pathways, nor any overall leadership, for child healthy weight that ran from pregnancy through to Primary 1. At a strategic level, there were distinct teams and individuals responsible for the different stages (pregnancy, early years and Primary 1) with limited integration between them. This could lead to boards having a particularly strong offering for one part of the system but much less for another. Regardless of the extent of the services in place within a board, there did not appear to be a great deal of join up between the different stages.

I don't necessarily think healthy weight is a big focus throughout that whole area [pregnancy to Primary 1]. I don't think there is consistency right across all the age groups. There are some bits where it is Healthy Start Vitamins and other bits on literacy and they look at it a little bit in 15 to 18 months, a little bit 27 to 30 months, and again age four to five, and it is kind of tacked on to a lot of people's remit in supporting a healthy lifestyle throughout the early years and the formative years I don't think it is consistent, particularly not with healthy weight across all those years.

Public health professional

A consistent handover protocol around child healthy weight did not appear to exist. When handovers (from midwives to health visitor, and health visitor to school nurse) did happen, information about past child healthy weight issues or interventions might be included on shared systems or via paper handover. However, the child healthy weight aspect was not highlighted specifically in any verbal handovers and was not prioritised. Health professionals identified these handover processes as an area for improvement.

In relation to the handover from midwives to health visitors specifically, the antenatal visits introduced as part of the UHVP, regular meetings between health visitor and midwife teams and the involvement of parents were all considered to improve the handover. However, even where these happened, weight issues were not generally a priority. The focus tended to be more on delivery and recovery. At its worst, communication between midwives and health visitors could be very poor, as illustrated by the quote below.

I often don't even hear when a baby in my caseload has been born.

Health visitor

Similarly, child healthy weight issues were not a focus of handovers between health visitors and school nurses. Indeed, there were health boards where school nurses only received information on pupils who were under child protection or being looked after. There was also evidence of handover processes varying at the individual school nurse level.

When we pass on to school nurses we really only highlight the children that are causing concern or had child planning meetings ongoing for things like autistic spectrum disorder.

Health visitor

Area for consideration (local health board level):

Improved pathways/co-ordination of services from preconception to Primary 1 - greater strategic oversight of child healthy weight across the system as well as practical improvements e.g., handovers between professionals (midwife to health visitor, and health visitor to school nurse)