Changes in the management of adult obesity

In the UK we still have one in four adults classified (by BMI) as clinically obese, and a more staggering two thirds of the adult population are either overweight or obese – meaning that more of the population are at an unhealthy weight than a healthy one. This shows no sign of reducing, with increasing numbers of children at an unhealthy weight, with nearly one in four of our children beginning Reception Year at school (aged four-five) being overweight or obese, which rises to one in three by the time they leave primary school in Year 6 (aged 10-11).

The McKinsey Report published in December 2014  suggested that more than 2.1 billion people worldwide (nearly 30 per cent of the total global population) are either overweight or obese, nearly two and a half times as many as the number who are under-nourished, with obesity now responsible for five per cent of all deaths, despite being a preventable condition. The global economic impact from obesity is estimated at roughly $2 trillion (2.8 per cent of GDP), which is roughly the same impact as smoking or the armed forces, war and terrorism.

Should current trends continue, half the global adult population will be obese by 2030. In the UK, the previous Foresight Report  published in 2007, projected that if nothing is done about the obesity crisis then over half of the UK population will be obese (as classified by BMI) by 2050, with direct and indirect costs potentially bankrupting the NHS with costs of £49.9 billion per year. The McKinsey Report suggested that in 2012 the total cost of obesity in the UK was already at £44.7 billion, second only to smoking.

What should be done?
What should be done has been a matter of debate for politicians, commissioners of services, the public and even clinicians working in the field of obesity for some time. The McKinsey Report reinforced the findings in the Foresight Report that suggested the causes of obesity are multi-factorial, and so any one single intervention is likely to have little impact. In the report’s own words, a systemic, sustained portfolio of initiatives, delivered at scale, is needed to address the burden, which is what clinicians have been arguing for. However, this has not been introduced despite the acceptance of successive governments of the need to tackle the crisis.

We still do not have obesity management as a mandated service provision within our NHS, nor the necessary funding required to finance it, nor any incentivisation for our healthcare professionals to prioritise its management.

We cannot expect change without some radical strategies to address these issues, rather than paying lip service to it by introducing more public health measures aimed at prevention.
The McKinsey Report estimated that a comprehensive programme, in the UK alone, could save the NHS £1.2 billion a year.  It stressed the importance of education and personal responsibility (albeit not in isolation), as well as individual behaviour change and a shift in societal norms. It clarified that public health campaigns for prevention have little evidence and are likely to have low impact, yet treatment interventions are well evidenced and can have much greater impact, yet the government and society still focuses too much on prevention, despite the fact that treating the overweight prevents obesity, and treating obesity prevents severe or ‘morbid’ obesity, and so on.

Furthermore, the focus of many government policies seems to be aimed at tackling childhood obesity. In our hearts we might feel that this may well make sense, to prevent the next generation of children becoming overweight or obese. However, whilst living in an obesogenic environment or perhaps even just a home environment where the parents do not eat the correct foods, or do not serve the correct portion sizes, or lead a sedentary lifestyle with insufficient physical activity, there is the possibility that any education (or weight reduction in the overweight/obese) is wasted and not be the best use of resources, as children (in particular young children) do not re-educate their parents.

An interesting clinical argument is to focus attention on adults and parents who are overweight and obese. By addressing their weight and unhealthy lifestyles, they can educate their own children and introduce behaviour change that will lead to a healthy weight and lifestyle, thereby tackling the problem in the adult and child population.

Speaking on the Health At A Glance: Europe 2014 report, Simon Stevens, the chief executive of NHS England said: “If we act together – as the NHS, as parents, as schools, the food industry, we can get back into shape. We know that for people at risk, losing just five-seven per cent of your weight can cut your chance of diabetes by nearly 60 per cent. If this was a pill we’d be popping it – instead it’s a programme of exercise, eating well and making smarter health choices, and we’re going to start making it available free on the NHS.”

What is being done?
Recently there has been focus on the care pathway for obesity management, specifically looking at the different tiers of intervention, criteria for accessing the different tiers, and who should have the responsibility for the commissioning of these services. The weight management pathway is now accepted to be formed by four tiers, and the Department of Health (DoH) recently demonstrated the differences between the Tiers as follows, but states it is for information rather than as a definition.

Tier 1: ‘Behavioural – Universal interventions (prevention and reinforcement of healthy eating and physical activity messages), which includes public health and national campaigns, providing brief advice’.

Tier 2: ‘Lifestyle weight management services, normally time limited’.

Tier 3: ‘Clinician led multidisciplinary team (MDT) – A MDT clinically led team approach, potentially including physician (including consultant or GP with a specialist interest), specialist nurse, specialist dietitian, psychologist, psychiatrist, and physiotherapist’.

Tier 4: ‘Surgical and non-surgical – Bariatric Surgery, supported by MDT pre and post-op’.

In April 2013, government health reforms made primarily Tiers 1 and 2 of these weight management interventions the responsibility of Public Health but moved this department to Local Authority control. Locally elected, non-medically trained individuals could now influence the purse-strings for essential NHS services such as weight management. Other pre-existing challenges remained such as the ‘postcode lottery’ of varying provision of bariatric surgery across the country. 

The Tier System
With the NHS restructure came NHS England recommendations, prepared by the NHS Commissioning Board (NHS CB) Clinical Reference Group for Severe and Complex Obesity, intended to address these concerns. Among other things, this document outlined the arrangements for funding of bariatric surgery for the population of England, and was intended to define the eligibility criteria. The proposals addressed some of the findings in the NCEPOD Report into bariatric surgery, which was concerned that sufficient medical management and psychological support was not being offered to patients prior to bariatric surgery, and the new guidelines have been largely welcomed by clinicians. In practice however, the NHS CB policy document for severe and complex obesity highlighted an even bigger variation in the availability of suitable Tier 3 non-surgical MDT services.

Prior to April 2014, there was huge variation in the availability of what would be considered Tier 3 specialist centres for the MDT provision of weight management. In some areas these services were being commissioned by Public Health England (PHE) and therefore local authority, in other areas they were being commissioned by Clinical Commissioning Groups (CCGs), but in the majority of areas they had no specific Tier 3 service, or a version of it was being provided by the surgical Tier 4 providers, which introduces a potential for what should be intensive medical management to prevent the need for bariatric surgery turning into a period of just pre-operative preparation for surgery.

Currently approximately 60 per cent of CCG regions have access to some form of Tier 3 intervention (suggesting that 40 per cent do not!), yet the majority of those that do are not in dedicated primary care based centres like the Rotherham Institute for Obesity, and instead a loose interpretation of Tier 3 services, or are delivered by surgical teams in a Tier 4 setting.

After considering a range of options, the DoH working party concluded that in terms of future commissioning responsibility, CCGs were the preferred option as the primary commissioners for local weight management multi-disciplinary team interventions (Tier 3). Furthermore, NHS England should consider the transfer of all but the most complex adult bariatric surgery (Tier 4) to local commissioning once the predicted increase in volume of Tier 4 activity has been realised and once locally commissioned Tier 3 services are shown to be functioning well, and that local authorities should remain as the commissioners of Tier 1 and 2 of the obesity care pathway.

Perhaps the biggest shake-up within the NHS management of obesity will come on April 2016 when the transfer of responsibility for commissioning bariatric surgery passes from NHSE to CCGs. Having the same commissioner responsible for Tiers 3 and 4 would also hopefully encourage increased investment at a Tier 3 level, in order to realise potential savings from reduced need for expensive Tier 4 bariatric procedures, as a consequence of successful intensive medical management. However, the concern is whether CCGs are prepared for this major change.

It may be ironic that despite some significant changes in the care pathway for weight management over the last few years, little detail has made it into the media spotlight. The likely cause for this is most likely that more press attention is given to advocates of an unworkable sugar tax that for a number a reasons is unlikely to help solve the obesity epidemic. If we want to tackle obesity, we need to review the evidence and be radical in our strategy without going down the route of a ‘nanny state’. Even in times of austerity, the health-economic argument for treating obesity is clear, but it will not happen without more action from policy makers.
 
Further information
www.nationalobesityforum.org.uk