1. 1 Healthy Start London Region: Workshop 2 7 th March 2011 Anna Kitt Anna.Kitt@dh.gsi.gov.uk

2. 2 Agenda TimeItemLead 9.30amRefreshments 9.45amWelcome & overviewAnna Kitt 10amCase Studies – Sharing best practice Ealing PCT Westminster PCT Eula Green Eva Hbronova & Anna Varela Raynes 11amCoffee 11.15amHealthy Start Update - LondonAnna Kitt 12pmUpdate from the Healthy Start Policy team Moragh Loose 12.30pmLunch

3. 3 Replaced Welfare Food Scheme in 2006 A statutory scheme for PCTs A nutritional safety net A public health tool

4. 44 What does Healthy Start provide? Vouchers:Vitamins: Liquid milkFor women Fresh fruit and vegetablesFor children Infant formula milk Eligible families are able to get these from 10wks pregnant to their child’s 4 th birthday AND: Information on breastfeeding and healthy eating through the Healthy Start magazine sent with the vouchers

5. 5 Why give Vitamins? Sufficient evidence to convince COMA and SACN to recommend supplementation NICE report on Maternal and child nutrition (March 2008) places the onus on PCTs to ensure supplementation happens Source: COMA – Committee on Medical Aspects of Food and Nutrition Policy SACN – Scientific Advisory Committee on Nutrition NICE – National Institute for Clinical Excellence

6. 6 Healthy Start eligibility is based on patient’s financial status i.e. Whether they are on benefits or under 18 yrs of age The following groups are at risk of Vitamin D deficiency: all pregnant & breastfeeding women all infants & children (6mths to 5yrs) unless fed 500mls infant formula People whom lack exposure to the skin People from BME groups with darker skin

7. 7 Children’s Drops Code:ABX 072 Cost to PCT:£1.61 Cost when selling: £1.77 Available to:Children; 6 months – 3 years Contains:233mcg Vitamin A 20mg Vitamin C 7.5mcg Vitamin D One bottle:10 mls (8 week supply) Daily Dose:5 drops Classification:General Sales List Medicine Manufacturer:SSL International Women’s Tablets Code:ABX 073 Cost to PCT:82p Cost when selling: 90p Available to:Women; pregnant and until child is 1 yr old Contains:70 mg Vitamin C 10 mcg Vitamin D 400 mcg Folic Acid One bottle:56 tablets (8 week supply) Daily Dose:1 tablet Classification:Multivitamin Food Supplement Manufacturer:Bayer Vitamin Facts

8. 8 Vitamin D Supplement Recommendation People at risk of vitamin D deficiencyDaily vitamin D supplement All pregnant and breastfeeding women10µg/day All infants and children from 6 months to 5years, unless they are drinking 500mls (a pint) of infant formula a day at any time during this age range (If there is any doubt about the mother’s use of vitamin supplements during pregnancy and/or breastfeeding, breastfed infants will benefit from vitamin D supplements from 1 month) 6 months to 5 years - 7µg/day People whom lack exposure to the sun e.g. people confined indoors for long periods and those who cover their skin for cultural reasons 10µg/day People from ethnic minorities who have darker skin, because their bodies are not able to produce as much vitamin D. Clinical deficiency has been most reported among children of African- Caribbean and South Asian origin. 10µg/day

9. 9 FoodVitamin D content (mcg) 100g canned sardines in tomato sauce 7.5 1 boiled egg1.1 30g Fruit n’ Fibre0.6 1tbsp low fat spread0.4 100g Salmon4.5 Can a healthy diet provide adequate vitamin D? Simple Answer NO!

10. 10Univ WestminsterCarol Williams, 2009 Vitamin D deficiency is Sunlight Deficiency UK :13-28% of women of childbearing age have low plasma vitamin D levels 2 hours/week sunlight exposure if face only, 30 minutes face, arms and hands is sufficient for Vitamin D synthesis. (SPF 8+prevents) Darker skin blocks some of the UV rays, so need more exposure to make Vit D In UK the wavelength of sunlight received in winter (November to March) is not effective at making vitamin D

11. 11 There is no funding to provide universal Healthy Start vitamins free at my PCT Implement Healthy Start pathway with distribution points where the vitamins can be sold & locally advertise this Signpost women to their local pharmacy e.g. Boots, Tesco, Holland & Barrett to buy vitamin D and folic acid supplements Check there is Healthy Start information at the booking appt (10wks) maternity pack

12. 12 Vitamin D Supplements Prices correct Nov 2010 Boots 12.5mcg (90 tablets) £2.79 ASDA 10mcg (60 tablets) £2.23 Holland & Barrett 10mcg (100 tablets) £3.19 Healthy Start (DH) 10mcg (56 tablets) 90p

13. 13 What is the role for Public Health? Provide strategic leadership for Healthy Start Work alongside Commissioners to ensure the specification for Maternity and Early Years provider services includes the Healthy Start pathway Identify local needs in the local population and incorporate this into the Joint Strategic Needs Assessment (Healthy Start quarterly report, DH) e.g. Are vitamin distribution points in areas of deprivation in the borough?

14. 14 Effective Distribution Healthy Start pathway development & implementation Key distribution points identified & advertised to increase consumer demand Administrative staff are trained to issue vitamins Each location is responsible for ordering vitamins, ensuring that stocks are maintained & take-up is monitored

15. 15 Working with Health Professionals Ongoing training for health professionals Midwives promote the scheme at booking appointments, health visitors follow this up with guidance at home visits and GPs are aware of the scheme

16. 16 Raising Awareness Promotional materials developed to supplement those available nationally Healthy Start application form available at all GP surgeries, Children Centres and is within the booking appointment pack Vitamin distribution points are published on Healthy Start (DH) website

17. 17 Have you identified training needs in your local area? All health professionals including Midwives, Health Visitors, GPs need to discuss the importance of vitamin D for pregnancy and breastfeeding. Particularly important for those BME groups with darker skin as their vitamin D requirements will be higher Are there administration training needs?

18. 18 Discussion points Has anyone identified distribution points at pharmacies or other outlets? What are the barriers to the work in providing effective distribution of vitamins? How could these barriers be overcome?

19. 19 Healthy Start uptake Healthy Start eligibility is based on snapshot data comparing data on the scheme against eligibility according to HRMC tax credits and Job CentrePlus ***England’s uptake 78.9%*** London’s uptake 78.1%

20. 20

21. 21

22. 22 Vitamin Uptake Vitamin uptake for both children’s and women’s tablets. In the last year… PCT with highest children’s drop uptake is Islington with 6.9% (Sept 10/11) PCT with highest women’s tablets uptake is Islington with 7.0% (Sept 10/11) PCT with highest Healthy Start uptake is Westminster with 85.1%

23. 23

24. 24

25. 25

26. 26 Number of women’s vitamins ordered compared with the potential number eligible 09/10

27. 27 Number of children’s vitamin drops ordered compared with the potential number eligible 09/10