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UK obesity services

UK parliamentary group publishes report on obesity services

(Credit: Obesity Action Coalition)
The report said that there was a clear lack of a financial incentive for GPs to refer patients into obesity services as the current General Medical Services contract does not incentivise referral for adults or children
In many places across the country obesity services are not being commissioned, meaning that eligible patients are denied treatment

A national (UK) obesity strategy for both adult and childhood obesity should be developed and implemented by the Government, with input from key stakeholders, according to a report from an All-Party Parliamentary Group (APPG) on obesity. The report, “The current landscape of obesity services: A report from the All-Party Parliamentary Group on Obesity”, is part of an inquiry into the current landscape of obesity services and is designed to highlight barriers and opportunities for government, commissioners and other stakeholders, to improve equitable access to obesity prevention and treatment programmes.

The inquiry is gathering evidence that highlights the current provision of obesity services, shines a spotlight on barriers to better provision and seeks to establish a consensus around potential solutions. The inquiry as received around 1,500 submissions in total - 48% of submissions from people with obesity and 52% from healthcare professionals and wider stakeholders. Following the analysis of inquiry survey responses, the Group takes the view that much of the stigma associated with obesity comes from a lack of understanding of what obesity actually is.

 “Evidence-based NICE guidance regarding bariatric surgery is also not being implemented. This is deeply counterproductive given the demonstrable savings which can be gained from the application of the right preventative measures and the right treatment at the right time."

For example, there is a perception amongst the general public that obesity is simply a result of overeating, laziness, and that it is self-inflicted, however obesity is a complex and multi-faceted condition, with influencers including mental health, genetics and environment. The reports states that 61% of people with obesity who responded to the online survey thought obesity is a disease with 26% against, and 14% saying they did not know. Amongst HCPs/commissioners/NHS representatives, 73% responded that they thought obesity is a disease, with 20% against and just 7% saying they did not know.

Obesity services

With regard to obesity services, the report said that there was a clear lack of a financial incentive for GPs to refer patients into obesity services as the current General Medical Services contract does not incentivise referral for adults or children.

Although a range of NICE recommendations exist for Clinical Commissioning Groups (CCGs) about the levels of service they should be providing for people with obesity (obesity prevention, maintaining a healthy weight and lifestyle weight management services), the report state that the evidence demonstrates the competing priorities of commissioners leads to a ‘postcode lottery’ for individuals with obesity looking to access services.

Figure 1: Tier 1 & Tier 2 services are commissioned by Local Authorities (LAs) and Tier 3 & Tier 4 services are commissioned by Clinical Commissioning Groups (CCGs)

The APPG highlighted the ‘patchy access’ to Tier 1 to Tier 4 obesity services across the country with over a third of people with obesity who responded to the APPG’s online survey stating that they have not accessed any lifestyle or prevention services. Of those who reported that they have accessed lifestyle and prevention services, 39% found it incredibly or moderately difficult to do so.

In addition, a recent Freedom of Information Request received responses from 88% of LAs and 91% of CCGs - which found that only 52% of LAs commission Tier 1 services, while 82% commission Tier 2. It also found that 57% of CCGs commission Tier 3 services and 73% commission Tier 4 services. This survey also found that ten LAs and seven CCGs do not commission any weight management services at all. An additional analysis of obesity services found that 27% of surveyed LAs indicated that they have decommissioned elements of their obesity service in the past five years.

The Royal College of Physicians noted that the transfer of commissioning responsibility from NHS England to CCGs has led to further inconsistencies and regional variability in delivery of the essential service – as CCGs are able to issue their own obesity treatment strategies access to treatments depends on their geographical location, not on their clinical needs.

Bariatric surgery

Although bariatric surgery is widely recognised as the most effective treatment for people with morbid obesity to allow substantial, sustained weight loss and to improve or resolve obesity-associated comorbidities such as diabetes, a study supported by the National Institute for Health Research found that increasing access to surgery for patients with obesity is likely to save lives, reduce diabetes and be a cost-effective use of NHS resources. However, fewer than 7,000 patients have surgery on the NHS each year, when the number entitled exceeds a million.

“The postcode lottery in access to treatment is unacceptable.”

The 2014 UK National Bariatric Surgery Registry found that out of a sample of 30,933 follow-up entries, over 60% of patients with obesity and Type 2 diabetes returned to a state of no indication of Type 2 diabetes only one year after primary surgery. It is known that surgery roughly halves the microvascular complications of Type 2 diabetes, and that surgery reduces long-term mortality by around a third.

Furthermore, the average cost of treating one of these patients’ diabetes is around £3,717 per annum - the cost of performing bariatric surgery is around £6,000. The cost of one year of diabetes treatment and one episode of surgery is £9,717, whereas the cost of three years of diabetes treatment - bearing in mind this would continue for many years - is £11,151. Therefore, surgery becomes cost neutral.

Currently in the UK NICE recommends that intensive weight management programmes incorporating diet, activity, pharmacotherapy and support for behavioural change are a prerequisite to bariatric surgery. However, in many places across the country these services are not being commissioned, meaning that eligible patients are denied treatment. Equally, patients who choose not to opt for bariatric surgery can be referred back to Tier 3 services, but this is only possible where these services exist.

A Freedom of Information sent to all registered CCGs in England (198/208 = 95.2% responded), found that 135/198 (68.2%) commission a Tier 3 service and a further six (3.0%) were in the process of setting up a service. Some 39 CCGs (19.7%) reported having no Tier 3 service, while another three (1.5%) had recently decommissioned their service.

The APPG stated that while prevention must be a strong focus of any national obesity strategy, “the postcode lottery in access to treatment is unacceptable.”

The report also asks whether mandating a minimum level of obesity service within a particular healthcare economy (such as each Sustainability and Transformation Partnership (STP) footprint or Integrated Care System) would lead to more equitable access to services for people with obesity. Subsequently, the APPG supports the development of a nationwide strategy for adult obesity, as well as the adoption of the Childhood Obesity Strategy, which has already been developed.

According to the report, earlier intervention and the proliferation of Tier 3 services is clear as they are effective in tackling complex cases of obesity, which provides an opportunity to reduce costs in the future before the costly comorbidities set in. The report recommends that the government should commission or support the development of a thorough, peer-reviewed cost benefit analysis of earlier intervention and treatment of patients with obesity.

The report states that there are substantial socioeconomic drivers of obesity, with lower socioeconomic groups associated with higher levels of obesity, in part due to greater availability of food, particularly unhealthy food, that is cheaper and easier than more healthy options.

“The findings illustrate a need for new policies to reduce obesity and its socioeconomic inequality in children in the UK, with a focus on societal factors and the food industry, rather than simply individuals or families,” the report states.

Some of the key recommendations of the report were:

  • Obesity/weight management training should be introduced into medical school syllabuses to ensure GPs and other healthcare practitioners feel able and comfortable to raise and discuss a person’s weight, without any stigma or discrimination.
  • The Government should implement a 9pm watershed on advertising of food and drinks high in fat, sugar and salt to protect children during family viewing time.
  • The Government should lead or support efforts by the clinical community to investigate whether obesity should be classified as a disease in the UK, and what this would mean for the NHS and other services.
  • The Government should commission or support the development of a thorough, peer-reviewed cost benefit analysis of earlier intervention and treatment of patients with obesity.
  • 88% of people with obesity reported having been stigmatised, criticised or abused as a direct result of their obesity.
  • 94% of all respondents believe that there is not enough understanding about the causes of obesity amongst the public, politicians and other stakeholders.
  • 26% of people with obesity reported being treated with dignity and respect by healthcare professionals when seeking advice or treatment for their obesity, 42% of people with obesity did not feel comfortable talking to their GP about their obesity.

Conclusions

“This report has demonstrated that the causes of obesity are many and are complex – but that the system set up to prevent obesity from developing in childhood and adulthood, and which is designed to treat obesity amongst those with easily rectified problems and more complex cases, is inadequate,” the report concludes. “Evidence-based NICE guidance regarding bariatric surgery is also not being implemented. This is deeply counterproductive given the demonstrable savings which can be gained from the application of the right preventative measures and the right treatment at the right time…A whole system approach is needed at both the national and local level. Few aspects of government are exempt from needing to pay attention to this looming issue. It is hoped the Government takes note of the recommendations set out in this report. This way, we will be able to take a big step forward in the fight against this destructive condition.”

To access this report, please click here

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