WDLAG is a Statutory Advisory Group to the Welsh Therapies Advisory Committee (WTAC). Membership comprises Heads of Service and Operational Dietetic Managers from all NHS Wales Health Boards/LHB and Velindre Trust, and representation from Registered Dietitians in Public Health Wales and Cardiff Metropolitan University. It’s role is to address issues relevant to managing Nutrition and Dietetic Services in NHS Wales and to provide specialist dietetic advice to WTAC.

PHDiW are a group of Specialist Dietitians employed within University Health Boards or Public Health Wales (NHS). Public Health Dietitians provide credible and unbiased nutrition information, accredited training and resources to support key settings (such as nurseries, schools, and care homes), organisations (such as Communities First, Families First and the voluntary sector), communities, and members of the public to make healthy food choices with knowledge and confidence. Community Dietitians are trusted stakeholders frequently engaged in a range of local and national working groups, and have assisted, or led in the development of food/ nutrition related policies and guidelines, including the All Wales Obesity Pathway, Food and Health Guidelines for Early Years and Childcare Settings and the Nutrition in Community Settings Pathway.

We welcome this opportunity to submit written evidence in response to the Poverty in Wales: Communities First - lessons learnt consultation.

1. What worked and didn’t work about the Communities First programme

1.1 NUTRITION SKILLS FOR LIFE ™ (NS4L)(formerly the Increased Dietetic Capacity

Grant Scheme) funded by Welsh Government since 2006, working in partnership with Communities First has provided an opportunity to influence health and wellbeing of communities in Wales and address inequalities in health. This integrated partnership approach has worked well,  engaging with communities to cascade consistent, evidence based nutrition messages to support healthy eating and prevention of malnutrition.

1.2 NS4L  is a programme of quality assured nutrition skills training and initiatives

developed and co-ordinated by dietitians working in the NHS in Wales. Operating in all 7 Health Boards, the programme aims to support community workers, volunteers and peer leaders from health, social care and third sector organisations to promote healthy eating and incorporate food and nutrition skills into their work.

1.3 There are two key aspects to the programme;

1.3.1 Accredited nutrition skills training for community workers to help them to competently cascade nutrition messages and to support the development of community food initiatives.

1.3.2 Co-production of healthy eating initiatives with community groups. The programme aims to reach community groups who may not have the knowledge, skills and confidence to prepare and eat a healthy balanced diet. It supports community workers who complete accredited nutrition skills training to plan, implement and evaluate healthy eating initiatives at community level. This can include offering accredited practical cooking skills (Get Cooking, Come and Cook), nutrition skills or weight management (Foodwise for Life) courses depending upon identified need. Courses are accredited by the Welsh awarding organisation Agored Cymru, enabling people to gain credit for learning, a route into further learning and employment opportunities.

1.4   NS4L  is a well established programme. Identifying and developing health assets (capacity, skills, knowledge, connections and potential) in communities, key to addressing the health inequalities agenda, is central to the programme. Up skilling health and community workers and community leaders in nutrition to enhance the reach, effectiveness and sustainability of community based nutrition interventions is a key strategy in building public health nutrition capacity in individuals, organisations and communities to effectively address population nutrition issues.

1.5   This model of nutrition skills training has been successfully embedded into Communities First programmes in Wales. Between April 2015 and March 2016 252 accredited Level 1 nutrition skills courses were accessed by 1514 people across Wales. As an example, in Aneurin Bevan University Health Board 90% of programmes were delivered by trained Communities First workers. Other nutrition initiatives include delivering the nutrition component of transition programmes from primary to secondary schools promoting healthy food and drink choices, promoting food co-ops, the Healthy Start scheme and Love Food Hate Waste messages. It has also influenced the development of the all Wales SHEP programme which is now being rolled out

1.6   Inequalities in health persist in Wales including diet relates inequalities in health e.g.

1.6.1 One in three children in Wales lives in poverty, a higher proportion than any other nation in the UK, equating to almost 200,000 children (Save the Children, 2017). Food poverty, defined as an inability to choose, buy, prepare and eat an adequate quantity of good-quality foods in keeping with social norms, is growing.  Food poverty is a crucial factor in the relationship between childhood deprivation and ill-health.

1.6.2   26.2% of children aged 4-5 entering reception year at school are overweight or obese including 11.6% obese (Public Health Wales, 2016:7). There is a strong relationship between levels of obesity and deprivation. The recent Childhood Measurement Programme showed 28.4% of children living in the most deprived areas of Wales were overweight or obese compared to 20.9% in the least deprived (Public Health Wales, 2016).

1.6.3 Poor nutrition in early life is linked to Adverse Childhood

Experiences (ACE) (Public Health Wales 2016:17). 16.9% children with no ACE have a poor diet compared to 32% with 4 or more ACE. This relationship remains after accounting for socio-demographic factors and impacts on future health and wellbeing.

There is a need for continued action to address these inequalities, delivered through population health systems that more strongly integrate NHS services with other public services and approaches to public health.

1.7 Giving children the best start in life is a crucial step towards addressing inequalities in health. Good nutrition and healthy weight is essential to mitigate against the risk of child and adult obesity and other chronic conditions including type 2 diabetes, cardiovascular disease, high blood pressure, some cancers, osteoarthritis and depression. Lifestyle choices pre-determining health risks in adulthood are made during childhood and adolescence.

1.8 By training those who work closely with, and understand the needs of local people, communities across Wales are supported to acquire new knowledge, skills and confidence to plan and prepare safe, affordable and nourishing meals for themselves and their families. NS4L provides opportunities for people to develop personal skills, improve health literacy and self efficacy and to gain confidence to take control over their own health.  Adult learning can have positive effects on health and wellbeing of participants, their families and the wider community, in part by improving employment outcomes, increasing social contact, and reducing unhealthy behaviours. It widens access to accredited learning for people in the most disadvantaged communities.

1.9   When considering what hasn’t worked well, some Communities First clusters were not  fully aware of the benefits of integrating the all Wales NS4L model into their provision and in some areas external providers were funded to deliver  nutrition  programmes, some of which may not have been quality assured or evidence based.

1.10 Clear criteria for delivery, monitoring and evaluation of nutrition interventions with minimum standards for training, standardised quality assurance and evaluation framework and formal links to NS4L would have ensured evidence based, quality assured nutrition programmes were delivered equitably across Wales.

1.11 The loss of Communities First has resulted in reduced capacity to deliver

community food and nutrition initiatives with fewer community based accredited programmes for people to access. Nutrition and practical food skills programmes are being withdrawn from deprived Communities First areas. This is a significant loss of trained staff, community assets and capacity which may take years to rebuild. Opportunities must be sought for this primary prevention work to continue, through trained workers, volunteers and peer leaders who understand the needs of local communities, if we are to reduce diet related inequalities in health and contribute towards improved health and wellbeing for present and future generations.

1.12 The loss of Communities First will result in reduced activity at Level 1 of the All

Wales Obesity Pathway (Welsh Government (2010) at a time when Welsh Government have committed to developing a national obesity strategy under the Public Health (Wales) Bill.

2. How local authorities will decide which projects continue to receive funding after June 2017

2.1  Local authorities should fund programmes that meet identified needs within their wellbeing assessment plans. With the recent announcement that Welsh Government will be legally obliged to develop a national obesity strategy and cross government work focussing on preventing ill health, health improvement programmes should be prioritised.

2.2 Funded programmes should be able to demonstrate a proven track record of performance and quality assurance.

2.3 We would welcome direction from Welsh Government informing local authorities about nationally funded programme such as NS4L to ensure a centrally co-ordinated approach. There is a lack of opportunity to influence funding allocation locally.

3. How different poverty reduction programmes (Communities for Work, Lift, Flying Start etc.) will change as a result of the end of Communities First.

3.1 Many Flying Start programmes work closely with Communities First and signpost families to NS4L programmes delivered by trained Communities First staff. Flying Start families will no longer be able to access nutrition initiatives in many areas. A recent audit undertaken with Flying Start Health Team managers and Dietetic Service managers showed that whilst all 22 programmes are accessing nutrition skills training for staff through the NS4L programme, only 4 programmes fund a dedicated dietetic service that can support community initiatives including NS4L Level 1 accredited courses.

3.2 There is an opportunity, with appropriate resource, to integrate the NS4L training model into all Flying Start programmes. This would ensure that all populations covered by Flying Start programmes across Wales can benefit equally. A prudent “once for Wales” approach would enable a service that is efficient and equitable, quality assured and delivered by appropriately qualified health professionals.