NHS England » Complications from Excess Weight services for children and young people: commissioning toolkit

Purpose

This toolkit supports integrated care boards (ICBs) to continue commissioning high-quality Complications from Excess Weight (CEW) services for children and young people. It sets out the key service characteristics that ICBs should consider when commissioning these services, informed by the National Institute for Health and Care Research (NIHR)-funded evaluation of CEW services.

Population need

Evidence demonstrates that without effective early intervention, obesity persists into adulthood in the majority of cases (Simmonds, Llewellyn, Owen and Woolacott, 2015), driving significant long-term ill health with profound consequences for individuals, families, and demand on health systems.

Excess body weight in childhood affects almost every organ system in the body (Marcus, Danielsson and Hagman, 2022) and is associated with serious long-term conditions including cardiovascular disease, type 2 diabetes, hypertension, stroke, obstructive sleep apnoea, metabolic dysfunction-associated steatotic liver disease, and several cancers.

Previously, the majority of obesity-related complications were seen in adulthood; however, with the rise in the number of children and young people living with severe obesity, these complications are now being seen in a much younger population. Beyond physical health, childhood obesity is associated with poor mental wellbeing and significantly higher rates of school absence and subsequent NEET (not in education employment or training) status (An, Yan, Shi and Yang, 2017).

Much of the impact of severe obesity in children and young people only becomes apparent in adulthood (Marcus, Danielsson and Hagman, 2022), making the true cost across health and social care utilisation, productivity loss, disability, and premature death difficult to fully quantify in the near term.

What are CEW services

CEW clinics are intensive, specialist NHS clinics for children and young people living with severe obesity and high clinical need. Their purpose is to identify and treat the range of obesity-related complications while helping children and young people and their families or carers achieve their own goals through personalised, holistic treatment plans. Care is delivered by multidisciplinary teams, with integrated mental health, neurodiversity-aware and family-centred approaches.

CEW services are a key part of the 10 Year Health Plan shift from an NHS that focuses on treating illness to one that improves the lives of the population by preventing ill health or slowing its exacerbation. As per the Medium Term Planning Framework, ICBs must ensure their 5-year plans support strengthening specialist provision of obesity services, including through Complications from Excess Weight clinics for children and young people.

ICBs should consider CEW as the specialist tier within their whole obesity pathway for children and young people. Standard community (tier 2) weight management services are not equipped to manage the complex clinical and psychosocial needs of those living with severe obesity. A defining feature of CEW services is specialist-led multidisciplinary teams supporting complication management alongside wraparound holistic care. These services also address significant health inequalities experienced by this patient group, with data showing children living with severe obesity are more likely to live in deprived areas as well as higher rates in specific ethnic minority groups and those with neurodiversity (Robertson, Lee, Ghauri, Weeks, Johnson, White, 2024). 

Without intervention, the trajectory for these children is severe. Modelling indicates that without subsequent weight reduction a child aged 12 with a BMI-SDS* of 3.5 (corresponding to an adult BMI of approximately 40) has an average life expectancy of 42, nearly half the average life expectancy in the UK (The European Association for the Study of Obesity, 2024). 

* BMI SDS (Body Mass Index Standard Deviation Score) shows how a child’s BMI compares with other children of the same age and sex. This is used because children are still growing, so BMI needs to be interpreted in relation to normal growth patterns for their age and sex, rather than using the fixed BMI cut-offs used for adults.

NHS England has been piloting 38 CEW services across England since 2021. The CEW pilot is being independently evaluated through ENHANCE (Evaluating the NHS England Complications of Excess Weight Clinics for Children and Young People), an NIHR-funded study. It aims to determine the effectiveness of the services and to identify key components of care which have the greatest impact on outcomes.

Findings from the independent evaluation demonstrate that children and young people attending CEW services achieve clinically significant reductions in weight and benefits are evenly distributed across demographic groups, including deprivation, sex and ethnicity. Annex 1 contains a summary of key findings. This toolkit has been informed by the insights from the national evaluation with the objective of supporting ICBs to commission high-quality services for their population.

Key service characteristics

When commissioning CEW services, ICBs should consider the below key service characteristics:

Referrals

Accept referrals for children and young people aged 2 to 16 with severe obesity, defined as a BMI SDS of at least 2.68, for entry into the pathway.
Referrals should be accepted based on clinical need, with priority given to children and young people with diagnosed complications of obesity and the degree of clinical severity.
Referral criteria should reflect the wider local obesity pathway and available services. The pathway should support equitable access and avoid gaps in obesity treatment provision, recognising CEW as a specialist, tier 3-equivalent service for children and young people with severe obesity.
The local referral pathway should be clearly communicated across the system and should ensure that children and young people with significant need can be referred in a timely manner.
The service should consider providing accessible advice and guidance to referring clinicians through locally agreed mechanisms, such as e-RS, to support appropriate and timely identification of children and young people who would benefit from CEW input.
A waiting list management plan should be in place for waiting times exceeding 18 weeks, ensuring that children and young people receive support while awaiting their first appointment.

Configuration of the multidisciplinary team

Specialist weight management care should be delivered by a multidisciplinary team (MDT) taking a biopsychosocial approach. As a minimum, the MDT should include relevant expertise across paediatric medicine, dietetics, psychology, and family and social support.
The MDT should also have access to social care or child safeguarding expertise either through embedded provision in the CEW service, or via formalised links, to support assessment and management of social care needs.
The multidisciplinary team should demonstrate cohesive team working and regular case discussion.

Accessibility

Services should reflect their local population, adjusting for the prevalence of severe obesity to ensure equity of access.
The service should ensure that reasonable adjustments are in place for children and young people with learning disabilities, children with special educational needs and disabilities (SEND) and neurodiversity.
The service should ensure access to appropriate clinical equipment for children and young people with obesity, for example, bariatric chairs.

Engagement

Before the first scheduled appointment, children, young people and their families or carers should be provided with clear, accessible information about the service, including its purpose, what to expect and the likely duration of involvement. This should also provide an opportunity to understand the child or young person and family’s motivation and readiness to engage.
Services should actively design and implement flexible routes for accessing the service. This includes offering a choice of appointment formats, such as virtual, clinic-based or community outreach appointments, flexible scheduling, and proactive engagement strategies to mitigate barriers to engagement experienced by the CEW cohort.
Providers should have a clear, documented policy for managing was-not-brought appointments that recognises the complex barriers to engagement faced by children, young people and families within the CEW cohort.
Services should be co-designed with children, young people and their families or carers, with mechanisms for ongoing engagement and feedback to support continuous service improvement

Safeguarding

The service should have access to a named safeguarding lead with the expertise and protected time to manage safeguarding cases and provide oversight and guidance to the wider MDT.
Provision should be made within job plans for the proportionate time required to escalate and manage safeguarding cases.
Services should have access to the Child Protection Information System (CP-IS).

Biopsychosocial model and taking a child and family-centred approach

An individualised, holistic treatment plan should be developed with the child or young person and their family, taking account of biopsychosocial needs.
A person-centred approach should be taken that accounts for the wider determinants of health and healthcare inequalities.

Clinical assessment and monitoring

All children and young people should receive an initial in-person clinical assessment, including a physical examination, to assess for obesity-related complications and comorbidities.
In line with NICE NG246, appropriate investigations should be undertaken where clinically indicated. These should include blood pressure measurement, lipid profile, fasting glucose, HbA1c and/or oral glucose tolerance testing, liver function tests, endocrine investigations, and investigations for obstructive sleep apnoea.
Genetic testing using an R149 panel should be arranged for children and young people with severe early-onset obesity – defined as a BMI SDS greater than 3, with onset before 5 years of age – in the absence of significant syndromic features or another explanation.
Anthropometric and clinical measurements should be undertaken using calibrated medical devices.
In-person clinical review, including physical examination and repeat investigations where clinically indicated, should be undertaken at appropriate intervals.

Treatment pathway

Services are expected to provide treatment for a sufficient duration to support a clinically meaningful reduction in weight. On average, this is expected to be between 18 and 24 months; however, this may vary depending on individual patient considerations and the local obesity pathway.
Children and young people should be offered appointments with relevant members of the MDT at intervals determined by their individualised care plan, with the frequency and intensity of input adjusted to reflect clinical need and circumstances.

Delivery of services

Services should include face-to-face contact to support clinical assessment and monitoring.
Where appropriate, contact may also be delivered remotely through digital engagement tools or other non-face-to-face formats.
All services should be formally linked to a paediatric tertiary service to support any required specialist investigations.
Community-based clinic settings may improve accessibility for children and young people across wide geographical areas and should be considered where feasible.

Transitional care

Transition should be seen as a critical enabler for sustaining the benefits of the CEW intervention and preventing long-term complications. The service should develop and document links with adult specialist weight management services and/or adult speciality services for obesity-related complications.
A documented transition plan should be co-developed with the child or young person and their family or carer.
A named worker within the service should be identified to coordinate care before, during and after transfer, and input should be provided until the young person has begun treatment in adult services for obesity and/or speciality complication services
Services and ICBs should ensure continuity of any prescribing arrangements initiated within the CEW service before transitioning to another service, or before discharge to primary care. A named adult prescriber should be identified, where relevant.
The provider of the CEW service should reference the location and clinical team responsible for treating 16- to 17-year-olds within a standard operating procedure.
Where no appropriate onward service is locally available, CEW services retain responsibility for ensuring that discharge to primary care is safe and planned. They should provide the GP with explicit guidance on ongoing management, monitoring, and the criteria and pathway for re-referral should the child or young person’s needs escalate.

Read NHS England’s guidance on supporting young people to transition into adolescent and adult services.

Education and training

All staff in contact with children, young people and families must complete mandatory safeguarding training appropriate to their role.
MDT members should be supported to undertake continuing professional development, ensuring they have specialist skills and knowledge needed to treat children and young people presenting with physical health needs, mental health needs and social complexities.

Long-term data collection

Data must be collected in accordance with the national minimum dataset and recorded and retained in any relevant national clinical data system or audit.
Providers must routinely review service data as part of an ongoing cycle of quality improvement, using data on clinical outcomes, access, engagement and patient experience to identify areas for development and drive service improvement.
Providers should establish mechanisms for capturing the views and experiences of children, young people and their families throughout the care pathway, ensuring that service user feedback meaningfully informs service design, delivery and improvement.

Interdependent services

The provider of the CEW service should reference the location and clinical team responsible for caring for children with suspected or confirmed monogenic and syndromic obesity within a standard operating procedure.
CEW services should work in active partnership with education and social care. This includes liaising with schools to support attendance and learning, working with local authorities on social care needs, and ensuring that any educational needs are aligned with the child’s CEW care plan and reviewed in a coordinated way.
Services should prescribe appropriate pharmacotherapy for obesity and/or related complications as part of a comprehensive, multidisciplinary model of care, where clinically indicated. This should involve appropriate monitoring and be an adjunct to core care alongside wraparound support.
Services should manage referrals within locally agreed pathways to investigate and treat obesity-related conditions. This includes type 2 diabetes mellitus, polyendocrine metabolic ovarian syndrome (previously known as polycystic ovary syndrome), dyslipidaemia, idiopathic intracranial hypertension, metabolic dysfunction-associated steatotic liver disease, obstructive sleep apnoea and severe mental illness.
CEW services should play an active role in building system-wide knowledge and capability around non-stigmatising identification and management of complex obesity in children and young people, recognising that specialist expertise within the MDT has value beyond direct clinical care. This includes developing appropriate links with community-based weight management services and obesity surgery services.

Annex 1: Evidence from the ENHANCE evaluation

CEW services are delivering meaningful change

Findings based on data collected from January 2021 to July 2026 shows:

On average, children and young people attending CEW services achieve clinically significant weight loss, as measured by a reduction in BMI SDS. This is anticipated to improve their future quality of life and reduce costs to the healthcare system. In contrast, comparable children of the same age and sex who are eligible for CEW services but do not access them continue to show rising BMI SDS over time, indicating increasing health risk.
Nearly half of children and young people attending CEW services live in the most deprived quintile, and nearly 40% are from minority ethnic groups. Children and young people from the most deprived areas are achieving similar reductions in BMI SDS to those from less deprived backgrounds, a pattern not typically seen in weight management services.
Children and young people who have been seen within CEW clinics exceed NICE thresholds for severe obesity (BMI 99.6th centile + 2.68 SDs): the median BMI Standard Deviation Score (SDS) on entry was +3.73 SDs, equivalent to around the 99.99th centile and an adult BMI of 45.**
When assessed for comorbidities, many children and young people seen in CEW services present with significant medical complications. This includes metabolic dysfunction-associated steatotic liver disease (31%), dyslipidaemia (21%), obstructive sleep apnoea (17%)***, hypertension (14%) and type 2 diabetes (5%). These young people are likely to develop medical complications in every organ system over time, from early joint replacement to severe mental health problems.
There is a very high prevalence of neurodevelopmental and mental health conditions compared to the national average. This includes confirmed or suspected autism spectrum disorder (29%), learning disability (24%), ADHD (attention deficit hyperactivity disorder)/ADD (attention deficit disorder) (12%) and anxiety (9%).
The self-reported quality of life of children and young people presenting to CEW services is lower than children living with significant health conditions including cancer. This reduced quality of life spans every dimension of a child’s daily experience: their physical health, emotional wellbeing, ability to participate socially, and their outcomes at school. There is an improvement in self-reported quality of life following engagement with CEW services.

** For a 12-year-old boy who is tall for his age (170cm), a BMI at this level would correspond to a body weight of around 110kg. At the same height, a weight of approximately 60kg would fall within a healthy BMI range. This means he would be carrying around 50kg of excess weight, equivalent to approximately 6 stone 4lb.

*** Metabolic dysfunction-associated steatotic liver disease: liver inflammation and damage caused by a buildup of excess fat in the liver. This was formerly known as non-alcoholic fatty liver disease, or NAFLD

Dyslipidaemia: an unhealthy imbalance of fats in the blood, such as having cholesterol or triglyceride levels that are too high or too low.

Obstructive sleep apnoea: a sleep disorder where a person’s breathing repeatedly stops and starts because their throat muscles temporarily relax and block the airway. In children, this can affect the developing brain and also increase the risk of cardiovascular disease.

Annex 2: How is ‘severe obesity’ defined?

Unlike adults, for whom obesity is defined by fixed BMI thresholds, children’s weight classifications are measured relative to a historical reference population, the UK90 growth data, derived from a survey of 37,700 children across England, Scotland and Wales.

A child’s BMI is expressed as a Standard Deviation Score (SDS), which indicates how far their BMI deviates from the average for children of the same age and sex in that 1990 reference population.

NICE classifies children as living with obesity when their BMI exceeds the 98th percentile of the UK90, meaning their BMI is higher than 98% of children in the reference population of the same age and sex. Children living with severe obesity are those whose BMI exceeds 99.6% of children in the reference population. Severe obesity therefore represents the uppermost extreme of this distribution, capturing children whose BMI deviates most significantly from the UK90 norm and who are at greatest risk of weight-related health complications.

Data from the National Child Measurement Programme shows that in England 2.9% of children in reception and 5.6% of children in year 6, live with severe obesity. There are also differences based on ethnicity and deprivation: for example, in year 6 children, severe obesity prevalence was highest among Black Caribbean children (10.4%) and the prevalence of severe obesity was over 4 times as high among children living in the most deprived areas (9.0%) compared with children living in the least deprived areas (2.2%). Data from the National Child Measurement Programme at various geographical splits, including by ICB level, can be accessed on Fingertips.

Publication reference: PRN02472

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