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The currentlandscape ofobesity services:a report from the All-Party ParliamentaryGroup on Obesity

This is not an official publication of the House of Commons or the House of Lords. It has not been approved by either House or its committees. All-Party Parliamentary Groupsare informal groups of Members of both Houses with a common interest in particular issues. The views expressed in this report are those of the group.

ALL-PARTY PARLIAMENTARY GROUP ON OBESITY

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The current landscape of obesity services

Acknowledgements

The All-Party Parliamentary Group on Obesity would like to thank all those who submitted evidence to the APPG’s inquiry and who disseminated the online survey through their networks.

The Group would also like to thank the individuals who gave oral evidence to the inquiry:

■ Professor Rachel Batterham, Head of the Centre for ObesityResearch, University College London and the UCLH BariatricCentre for Weight Management and Metabolic Surgery

■ Dr James Cavanagh, GP with a specialist interest in Obesityand Bariatric Care

■ Maggie Clinton, member of Obesity Empowerment Network

■ Dr Hilda Mulrooney, Senior Lecturer in Nutrition, KingstonUniversity; representative of the British Dietetic Association

■ Mr Christopher Pring, Specialist Upper GI, Laparoscopic andBariatric Surgeon

■ Professor Pinki Sahota, Professor in Nutrition and Childhood Obesity, Leeds Beckett University

APPG officers:

■ Andrew Selous MP - Chair

■ Professor the Baroness Finlay of Llandaff – Vice Chair

■ The Baroness Jenkin of Kennington – Vice Chair

■ Eleanor Smith MP – Vice Chair

■ The Rt Hon the Lord Warner – Vice Chair

PB Consulting is paid by a grant from Johnson & Johnson,Medtronic and Novo Nordisk to act as the APPG’s secretariat.

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The All-Party Parliamentary Group on Obesity

4 Foreword

6 Summary of recommendations

7 Key inquiry findings

8 About the APPG’s 2018 inquiry

9 Understanding obesity: education, causes and stigma

14 Prevention of obesity

16 The current landscape of obesity services

20 The future of obesity services

26 Conclusion

27 References

Contents

The World Health Organisation defines obesity as excessivebody fat that presents a risk to health. A crude measure ofobesity is the body mass index (BMI) which is a person’sweight (in kilograms) divided by the square of his or herheight (in metres). A person with a BMI of 30kg/m2 or moreis generally considered as having obesity. Obesity isconsidered a major risk factor for a number of chronicdiseases, including diabetes, cardiovascular diseases andcertain types of cancer. The Local Government Associationargues that obesity is considered to be one of the mostserious public health challenges of the 21st century.i

The latest figures from the National ChildhoodMeasurement Programme show that levels of childhoodobesity have hit a devastating all-time high. More than onein three children (34.2%) aged 10 to 11 years have a weightstatus classified as overweight or as being obese, up from

31.6% in 2006/07. The prevalence amongst adultsis also concerning, with 58% of women and

68% of men now classed as overweight orhaving obesity. Obesity prevalenceincreased from 15% in 1993 to 27% in2015. According to the UK ForesightObesity report, by 2050 – if currenttrends continue – 60% of men and 50%of women could have obesity.

Data from 2005/06, shows that the NHSspends around £5.1 billion on obesityrelated disease every year. This spend isequivalent to the salary of around 163,000nurses. The increase in obesity prevalencesince 2005/06 would suggest that the NHSis now spending considerably more onobesity related disease. An economicanalysis based on 2014 data suggested thathealth costs associated with being

overweight and having obesity costs the UKat least £27 billion every year, and this this is aproblem the country cannot afford to defer tothe next generation.

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Foreword

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This report from the All-Party ParliamentaryGroup on Obesity is part of an inquiry into thecurrent landscape of obesity services. It isdesigned to highlight barriers andopportunities for government, commissionersand other stakeholders to improve equitableaccess to obesity prevention and treatmentprogrammes.

As the Chair of the APPG, I saw the scale ofdisparity in service provision across thecountry. With the number of people withobesity projected to rise significantly in thecoming years, action must be taken to treatpatients with severe and complex obesity now,as well as strengthening preventionprogrammes and childhood obesityprogrammes to reverse this escalating trend.

I have been heartened to see the volume andquality of submissions to this inquiry, whichdemonstrates that there is a clear commitmentfrom a wide range of stakeholders to solve theobesity epidemic. I believe the APPG has aclear role in bringing together cross-partyrepresentatives, people with obesity, cliniciansand wider stakeholders to find an ultimate andlasting solution.

I would like to thank all those individuals andorganisations who submitted evidence to thisinquiry and who continue to support the workof the APPG.

Andrew Selous MP Chair of the All-Party Parliamentary Group on Obesity

With the number

of people with obesityprojected to

rise significantly in the comingyears, action

must be taken totreat patients

with severe andcomplex obesity

now, as well asstrengthening

preventionprogrammes and

childhood obesityprogrammes to

reverse thisescalating

trend.

“

”

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■ A national obesity strategy for both adult andchildhood obesity should be developed andimplemented by the Government, with input fromkey stakeholders. This should look to strengthenexisting services and replicate best practiceacross the country.

■ Obesity/weight management trainingshould be introduced into medical schoolsyllabuses to ensure GPs and other healthcarepractitioners feel able and comfortable to raiseand 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 protectchildren during family viewing time.

■ The Government should lead or support efforts by the clinical community to investigate whetherobesity should be classified as a disease in theUK, and what this would mean for the NHS andother services.

■ The Government should commission or supportthe development of a thorough, peer-reviewedcost benefit analysis of earlier intervention andtreatment of patients with obesity.

Summary of recommendations

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Key inquiry findings

88%of people with obesity reported having beenstigmatised, criticised orabused as a direct result of their obesity

94%of all respondents believe that there is not enoughunderstanding about thecauses of obesity amongst the public, politicians and other stakeholders

26%of people with obesity reported being treated withdignity and respect byhealthcare professionals when seeking advice ortreatment for their obesity

42%of people with obesity did not feel comfortabletalking to their GP about their obesity

> 1/3of people with obesity who completed the surveystated that they have notaccessed any lifestyle orprevention services

39%of people with obesity who accessed lifestyle and prevention services found it incredibly ormoderately difficult to do so

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The All-Party Parliamentary Group on Obesitylaunched its inquiry into the ‘Current landscapeof obesity services’ in February 2018.

The aim of this inquiry is to gather a body ofevidence that highlights the current provision ofobesity services, shines a spotlight on barriers tobetter provision and seeks to establish aconsensus around potential solutions.

The inquiry consisted of an online survey whichposed questions about their experience topeople with obesity as well as healthcarepractitioners. The inquiry also invited submissionsof email evidence to the group secretariat. Theinquiry received around 1,500 submissions intotal. This is made up of 48% of submissions frompeople with obesity, and 52% healthcareprofessionals and wider stakeholders. An oralevidence session was also held, where a groupof experts were invited to Parliament to presentformal oral evidence.

About the APPG’s 2018 inquiry

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63% of adults in England are overweight orhave obesity.ii Yet for a condition that hasbecome the norm for almost two thirds of theadult population, obesity remains largelymisunderstood, which is a major factor in the highlevels of stigma associated with obesity. Thegroup has sought evidence from healthcareprofessionals (HCPs) and people with obesity toimprove understanding of the stigma associatedwith obesity, what impact it has on the lives ofpeople with obesity, and how it does little to helppeople with their obesity. Research evidencedemonstrates the widespread nature of weightstigma in the UK,iii that weight stigma isexperienced in many settings,iv v and that peoplewith obesity respond maladaptively to stigma.vi

Respondents were then asked to offer their viewson the level of understanding of obesity, andwhether obesity should be classified as adisease.

Stigma associated with obesity

88% of people with obesity who responded tothe survey reported having been stigmatised,criticised or abused as a direct result of theirobesity. These negative experiences have a

detrimental impact on the lives of people withobesity, in many different ways. Respondentsreported experiencing stigma ranging in severityfrom bullying and teasing, missed jobopportunities, to being completely excluded byfamily members and friends.

“ ”I have spent my life being judged and ignored or

abused because of my weight. Even members of my family

don’t like or talk to me because of it.–

An oral evidence session undertaken by theAPPG highlighted some of the ways in whichstigma can have an impact on the lives of peoplewith obesity and why it does little to help reduceobesity. Stigma can reduce a person’s motivationby making them feel worthless. Motivation, aswas pointed out in the oral evidence session, isone of the main drivers in reducing weight andmaintaining weight loss.

“ ”I was called names all my life up to having my gastric

bypass. I had no confidence at all and felt worthless.–

The APPG was concerned by the number ofrespondents with obesity reporting theirexperience of being discriminated against as adirect result of their weight, particularly withregards to job opportunities. This is in line with

Understanding obesity: education, causes and stigma

63% of adults inEngland areoverweight or have obesity

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research conducted by Flint and Colleagues(2016), which evidenced discrimination in theworkplace recruitment process.vii Numerousindividuals stated that they have missed out onjobs, been overlooked for promotions and evenfelt that their job was under threat because oftheir size. This has a direct impact on the careerprospects of people with obesity, as well as theirself-worth, esteem, earning capacity and evenliving standards.

“ ”Finding a job is the worst. I have spoken to employers

and they exclaim how perfect afit I am for the position.

Once I go in for a face to face it is very different. I have hadpeople look me up and down and actually ask me if their

available job will interfere withmy dieting. Other instancesinclude people pointing or

staring and worst of all, children actually asking theirparents, "why is she that big",and the parents say "because

she eats too much."–Stigma associated with obesity may negativelyaffect the mental health of people with obesityand may in fact lead to weight gain. While thecauses of obesity are complex, it is widelythought that mental health is one of the maindrivers. Having been abused or stigmatised dueto their weight, people with obesity may consumeunhealthy food, overconsume, or partake in lessexercise in a way that would not have beennecessary had the abuse not taken place, whichmay exacerbate the obesity.

“ ”Bullied at school, not thought as highly of by the opposite sex.This damages self-confidence,

and what once may have been aphysical issue, turns into apsychological one, or was it

psychological in the first place?–Stigma within the healthcare setting

Not all stigma associated with obesity comesfrom the general public. Just 26% of people withobesity responding to the inquiry surveyreported being treated with dignity and respectby healthcare practitioners when seeking adviceor treatment for their obesity. By contrast, 17%said they were not treated with dignity andrespect, and 57% said they were treated betterby some healthcare practitioners than others.

Oral evidence presented to the APPG as part ofthe inquiry suggests that stigma in healthcaresettings can often arise from a lack of educationon how to address a person’s obesity. Thehealthcare setting should be a “safe space” forpeople to talk openly and comfortably about any

Just

26%reported beingtreated withdignity andrespect

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healthcare problem. Failure to do so oftendiscourages patients from seeking help andsupport. If obesity is to be tackled, people withobesity must feel comfortable seeking help oradvice, and healthcare professionals should feelable and comfortable to raise and discuss thiswith individuals. Results from the inquiry surveyin this area were mixed, with 58% of people withobesity indicating they felt comfortable talkingto their GP about their obesity, and 42%indicating they did not feel comfortable.

“ ”Obesity suffers from significant stigma – and it

should also be recognised thatfor health professionals,

obesity is a ‘low status’ area towork in. In a clinical sense,

this also leads to healthprofessionals ‘ducking’ the issue of obesity when being

consulted about children withobesity for other reasons (e.g.

asthma). Professionals perceivethey lack the skills to have these

‘difficult’ conversations orperceive that they may causeharm by raising the issue of

obesity with CYP and families.This can be particularly

challenging where there isintergenerational overweight

and obesity.

- Royal College of Paediatrics and Child Health–

Medical interventions are rendered useless if thepeople they are designed for do not feelcomfortable engaging with them. Equally, it isimportant to ensure that healthcare professionalsare trained and supported to raise difficult andpotentially awkward conversations in a sensitiveand constructive manner. This reportrecommends that obesity/weight managementtraining be introduced into medical schoolsyllabuses to ensure GPs and other HCPs feelable and comfortable to raise and discuss aperson’s weight, without any stigma. This mayalso involve putting less emphasis on BMInumbers and more emphasis on promotinghealthy behaviours.

“ ”I’ve never been treated with respect or dignity. I’ve never

received help when I’ve asked for it. I’ve asked for

tests and they’ve been denied.I’ve given up - I just accept

that I won’t ever get rid of myweight and will continue to bejudged by society and medical

professionals.–

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Understanding the causes of obesity

Following the analysis of inquiry surveyresponses, the Group takes the view that much ofthe stigma associated with obesity comes from alack of understanding of what obesity actually is.

94% of all respondents to the APPG’s surveybelieve that there is not enough understandingabout the causes of obesity amongst the public,politicians and other stakeholders. There is aperception amongst the general public thatobesity is simply a result of overeating, laziness,and that it is self-inflicted. This report does notintend to go into a detailed evaluation of thecauses of obesity; yet the inquiry received asignificant amount of evidence to support the factthat obesity is a complex and multi-facetedcondition, with influencers including mentalhealth, genetics and environment.

Despite this, the public, patients, healthcarepractitioners and others, are continually informedthat obesity is simple and easily manipulated,which contributes to greater perceptions ofindividual responsibility, when the evidencesuggests that many factors outside of a person’scontrol influence obesity. It should be noted thatthere are many sources within society thatcontribute to this simplistic view including themedia, education, healthcare and workplaces.viii

The role of the media, in particular, should not beunderestimated with regards to the inaccurate

Some of the causes of obesity as highlighted insubmissions to the APPG’s inquiry include:

junk food advertising

portion sizesabuse

Medications

Genetic predisposition upbringing

lifestyle choices

unhealthy products easy to buy

sedentary lifestyle

mental health problemsproduct placement in shops

unhealthy food promotions

inequalities and deprivation

94% believe that there is notenoughunderstandingabout the causes of obesity

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and stigmatising perceptions that are evident inUK children and adults. The media can also playan important role in reducing weight stigma anddiscrimination.

While the cause of obesity is, fundamentally, animbalance in the uptake and use of calories, therecan be many reasons for this divergence. Thetime old phrase of “eat less and move more” initself is no silver bullet. The APPG believes that itis important to provide people with obesity withthe necessary support – both physical andmental – to enable them to maintain a healthyweight. There is no one-size-fits-all solution, butit is clear that where support is required, it shouldbe easily accessed. The issue of access will bediscussed later in this report.

Obesity as a disease

Obesity is currently recognised by the WorldHealth Organisation as a disease, as well as in theUSA, Canada and Portugal. It is not classified as

a disease within the UK. This inquiry gathered theopinions of respondents on whether or notobesity is a disease. 61% of people with obesitywho responded to the online survey thoughtthat obesity is a disease with 26% against, and14% saying they did not know. AmongstHCPs/commissioners/NHS representatives, 73%responded that they thought obesity is adisease, with 20% against and just 7% saying theydid not know.

Obesity is also a risk factor in other diseases suchas Type 2 diabetes, liver and heart disease. Forexample, a Diabetes UK audit found that 85% ofincluded people with Type 2 diabetes wereclassed as overweight or with obesity.ix It couldbe argued that the complications associated withobesity and complexity of treatments arecongruent with a disease classification and adiagnostic classification may improve access toeffective prevention and treatment programmes.

Responses to both the inquiry survey andcontributions to the inquiry’s oral evidencesession suggest that the classification of obesityas a disease could lead to improved outcomes.Firstly, it would remove the blame attached topeople with obesity and lead to reduced stigmain both public and healthcare settings. It wouldalso help to prioritise obesity services forcommissioning and encourage government andNHS decision makers to establish a nationalobesity strategy, as recommended by this report.

However, the impact this would have on the NHSmust be carefully analysed. An increase in thenumber of people accessing obesity services andtreatments could place strain on NHS resources.

■ This report does not intend to make a decision onwhether or not obesity should be classified as adisease, but the APPG recommends that theGovernment leads or supports efforts by the clinicalcommunity to investigate whether obesity should beclassified as a disease within the UK, and what thiswould mean for the NHS and other services.

61% of patientsbelieve obesity to be a disease

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A great number of detailed studies have beenundertaken to determine the best ways toprevent childhood and adult obesity. Eatinghabits are established early in life and aresignificantly influenced by the environments thatpeople experience every day. There needs to bea co-ordinated, whole-system approach to theprevention of obesity at both the local andnational level considering the impact of theenvironments in which people live, including thetotal household income, as well as the amountand type of food they consume.

This inquiry is not designed to conduct acomprehensive study of this part of the obesitypathway, but to highlight several immediateactions that can be adopted to achieve a short-term impact in the prevention of obesity inchildren and adults.

The one area in which this report will focus on interms of causation is the environment in which aperson grows up, as this has been demonstratedto have a profound impact on the likelihood ofdeveloping obesity. The food that is provided inthe home/schools and education centres/

religious centres and more; the examples set byrole models, parents, teachers, religious leadersetc.; and opportunities to be physically active indaily life influences weight status.

While in the past children from a lowersocioeconomic background might have beenmore likely to be underweight than children froma more advantaged background, they are nowmore likely to be overweight or have obesity.There is extensive research which analyses thesocioeconomic drivers of obesity, with lowersocioeconomic groups associated with higherlevels of obesity, in part due to greater availabilityof food, particularly unhealthy food, that ischeaper and easier than more healthy options.

The findings illustrate a need for new policies toreduce obesity and its socioeconomic inequalityin children in the UK, with a focus on societalfactors and the food industry, rather than simplyindividuals or families.

In August 2016 the Government published itschildhood obesity strategy, ‘Childhood obesity: aplan for action’. The top line recommendation in

Prevention of obesity

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this was a soft drinks industry levy, which hasbeen implemented and is showing early signs ofsuccess. The APPG would like to see theGovernment go further in taking action toimplement this strategy and other methods ofpreventing childhood obesity. In particular, theAPPG supports a 9pm watershed onadvertising of food and drinks high in fat, sugarand salt to protect children during family viewingtime. This recommendation also has support froma wide range of stakeholders; including JamieOliver, the Obesity Health Alliance, theAssociation of Directors of Public Health, theBritish Medical Association and Diabetes UK.

At the local level, a whole family and wholecommunity approach to tackling obesity is key.The Group therefore encourages a whole system

approach where each individual or institutionrecognises their role in taking steps tounderstand the environmental causes of obesity,such as portion size and sugar and fat contentlevels in food, and to help their children makehealthier choices. Parents are also encouragedto know their own healthy weight to reduce therisk associated with genetic obesity.

Initiatives are already in place in other areas tosupport prevention of obesity in children andadults, but these need to go further to achievethe impact needed. As such, the APPG believesthat serious steps to improve obesity preventionmust factor into a national obesity strategy forboth children and adults. This should promote awhole system approach.

■ The APPG recommends that the Governmentshould implement a 9pm watershed onadvertising of food and drinks high in fat, sugar and salt to protect children during familyviewing time.

The All-Party Parliamentary Group on Obesity hasa focus on the full pathway of obesity services;from prevention through to treatment.

Commissioning and funding structures

Structure

The rationale for reorganising the commissioningstructures for obesity services in 2016/17 was toincrease consistency in pathway management forobesity across the country, streamliningcommissioning in the process.

Funding

According to the Association of Directors ofPublic Health, public health funding in Englandwill be cut by 9.7% by 2020/21, £331 million incash terms in addition to the £200 million in-yearcut for 2015/16.x Reductions in public healthfunding will inevitably continue to have anegative impact on the levels of funding availablefor local authority funded obesity services,including weight management services.

There is a clear lack of a financial incentive forGPs to refer patients into obesity services. Thecurrent General Medical Services contract doesnot incentivise referral for adults or children.Furthermore, there is no financial incentive forGPs to assess a child’s weight.

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Tiers of obesity services

Obesity services within the UnitedKingdom are structured into Tiers,with each Tier providing a differentintervention:

The current commissioningstructure:

■ Tier 1 & Tier 2 services arecommissioned by Local Authorities (LAs).

■ Tier 3 & Tier 4 services arecommissioned by ClinicalCommissioning Groups (CCGs).

Tier 4: Bariatric

(weight loss) surgery

Tier 3: Specialist weight managementservices for people with severe

and complex obesity

Tier 1: Primary activity, population level

public health prevention,identifying those at risk,

referring into appropriateinterventions

Tier 2: Community based

weight management services

CCGs remain stretched; with ever increasingneeds of a growing, ageing population livinglonger with co-morbidities, yet with a finitebudget for delivering services. As such, serviceswhich are not mandated are often the first to becut in times of financial constraint.

The APPG’s inquiry has received evidence thatpoints to the problems of short-term fundingcycles for projects. In cases where short-termfunding grants have been made to set up aweight management programme, for example,when the funding runs out the service is nolonger able to run. This short-term approach tocommissioning means that people with obesityare missing out on the consistent care andsupport required to achieve their personal goals.A more long-term approach to funding ofservices, with appropriate incentivisationmechanisms, must be taken to achieve realchange.


A range of NICE guidance exists which makesrecommendations to commissioners about thelevels of service they should be providing forpeople with obesity; from obesity prevention,maintaining a healthy weight, and lifestyle weightmanagement services. The APPG, however, hasreceived evidence which highlights thecompeting priorities of commissioners, whichleads to a postcode lottery for individuals withobesity looking to access services.

The APPG is concerned about the patchy accessto Tier 1 to Tier 4 services across the country.Over a third of people with obesity whoresponded to the APPG’s online survey statedthat they have not accessed any lifestyle orprevention services. Of those who reported thatthey have accessed lifestyle and preventionservices, 39% found it incredibly or moderatelydifficult to do so.

This anecdotal evidence is supported by a recentFreedom of Information Request - which receivedresponses from 88% of LAs and 91% of CCGs -

which found that only 52% of LAs commissionTier 1 services, while 82% commission Tier 2.xi Italso found that 57% of CCGs commission Tier 3services and 73% commission Tier 4 services.xii

This survey also found that ten LAs and sevenCCGs do not commission any weightmanagement services at all.xiii

According to the Royal College of Paediatrics andChild Health, there is often confusion aboutwhether the Tier system commonly used in adultobesity applies to children and young people.While there are a number of community services(Tier 2/3 services), there are very few specialistservices for children and young people withobesity that manage and treat this patient groupwith extreme or morbid obesity (equivalent to Tier3/4). Such services have only arisen due tointerest and activism by individual professionals,and services exist in a commissioning vacuum –surviving only where individual trusts can ‘turn aprofit’ or individual managers support the service.

The British Medical Association argues thatinconsistent provision of specialistmultidisciplinary weight management units, whichoffer tailored weight management programmes

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>1/3 of respondentswith obesity have notaccessed anylifestyle orpreventionservices

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to those with severe and complex obesity tosupport them to lose weight, risks leaving manyvulnerable people without essential support tomanage their condition.xiv Indeed, the APPGreceived evidence which demonstrates that inmany cases, where both the individual withobesity and the HCP agree that referral to aweight management programme is necessary,there is no service to refer onto. This isunacceptable.

While several respondents to the APPG’s onlinesurvey acknowledged that althoughcommissioners may wish to run a service, it is notmandated that LAs or CCGs provide obesityservices, which makes these services vulnerableto commissioning cuts. LAs have experiencedyear on year public health budget cuts, which islikely to have had a significant impact on theirability to commission weight management andlifestyle interventions for people with obesity.One recent analysis of obesity services foundthat 27% of surveyed LAs indicated that theyhave decommissioned elements of their obesityservice in the past five years.xv

It should be considered whether mandating aminimum level of obesity service within aparticular healthcare economy (such as eachSustainability and Transformation Partnership(STP) footprint or Integrated Care System), wouldlead to more equitable access to services forpeople with obesity. In line with this, the APPGsupports the development of a nationwidestrategy for adult obesity, as well as the adoptionof the Childhood Obesity Strategy, which hasalready been developed.

Access to Tier 3 & 4 services

Bariatric surgery is widely recognised as the mosteffective treatment for people with morbidobesity to allow substantial, sustained weight lossand to improve or resolve obesity-associatedcomorbidities such as diabetes, thereby reducingmortality.xvi Indeed, a study supported by theNational Institute for Health Research found thatincreasing access to surgery for patients with

obesity is likely to save lives, reduce diabetes andbe a cost-effective use of NHS resources. Yetfewer than 7,000 patients have weight-losssurgery on the NHS each year, when the numberentitled exceeds a million.

“ ”Referral from my GP was initially refused. I re-applied

with psychiatrist letter which was reviewed by a panel and

was accepted.–The Royal College of Physicians, in its submissionto this inquiry, said, “The patchy delivery of [Tier3] service means that patients in many regionsare not only being denied access to this effectiveservice but also there is a blockade in thepathway of care meaning that they are alsounable to access bariatric surgery.” This iscatastrophic for patients who have finally soughthelp through primary care and find there isnowhere else for them to go, and many will notseek help again.

“ ”I had tried before manyyears ago and was turned

down due to lack of funding,which was why it came as

quite a surprise to me when the GP suggested it.–

Many people eligible for bariatric surgery maychoose not to have it, but there are criteria thatmust be met by individuals who do wish to havesurgery. Currently in the UK NICE recommendsthat intensive weight management programmesincorporating diet, activity, pharmacotherapy andsupport for behavioural change are a prerequisiteto bariatric surgery.xvii Yet in many places across

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the country these services are not beingcommissioned, meaning that eligible patients aredenied treatment. Equally, patients who choosenot to opt for bariatric surgery can be referredback to Tier 3 services, but this is only possiblewhere these services exist.

“ ”Took 20 years to gethelp and changing doctors

5 times. I was told to lose weight and that help would then be provided, so I did and then no help

was given. This happened twice.–

A recent Freedom of Information (FOI) requestwas sent to all registered CCGs in England, ofwhich 198/208 (95.2%) responded. The results

found that 135/198 (68.2%) commission a Tier 3service and a further six (3.0%) were in theprocess of setting up a service. 39 CCGs (19.7%)reported having no Tier 3 service, while anotherthree (1.5%) had recently decommissioned theirservice.

“ ”Still awaiting surgery. My only frustration is

having to have surgery through a different Trust

as my Trust does not perform the surgery

themselves.–The APPG believes that while prevention must bea strong focus of any national obesity strategy,the postcode lottery in access to treatment isunacceptable.

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The Five Year Forward View made clear that nowis the time to get serious about prevention. Acommon assumption is that, when it comes toobesity, prevention is limited to cutting down onsugary drinks. But prevention also extends toconditions such as diabetes, the causation ofwhich is closely linked to obesity.

The central problem for commissioners andclinicians is that, even if they are able todemonstrate the potential for future savingsthrough preventative care, it is not possible toreflect that on future balance sheets. Ifpreventative care is to be rolled out, themechanism must be made available for thefunding to come from a nationally earmarkedbudget, or for commissioning bodies to be ableto add presumed savings, backed up withevidence, to the balance sheets for future years.Effective prevention for conditions such asdiabetes and cardiovascular problems musttherefore include the treatment of individualswho currently have obesity. A failure to do thiscarries its own cost.

“ ”…there is a wide body of evidence that shows surgery is aneffective treatment option for Type2 diabetes and can be cost effectivefor the NHS. However, many people

who stand to benefit from thispotentially lifesaving treatment are

missing out due to needlessbarriers to obesity surgery services.Even people who meet the criteriafor the surgery are being made to

wait too long, even though weknow that people with Type 2

diabetes benefit most from thesurgery if it is carried out closer to

the time they were diagnosed.

- Simon O’Neill, Director of HealthIntelligence and Professional

Liaison at Diabetes UK, May 2016–

The future of obesity services

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Effective prevention for conditions such asdiabetes and cardiovascular problems musttherefore include the treatment of those whocurrently have obesity. A failure to do this carriesits own cost.

Understanding the cost of obesity

This report has, in very simple terms, attemptedto quantify the savings which could be madethrough the better use of a Tier 4 intervention,such as bariatric surgery.

The 2014 UK National Bariatric Surgery Registryfound that out of a sample of 30,933 follow-upentries, over 60% of patients with obesity andType 2 diabetes returned to a state of noindication of Type 2 diabetes only one year afterprimary surgery.xviii In short, they were able tostop their diabetic medications. It is also knownthat surgery roughly halves the microvascularcomplications of Type 2 diabetes, such asPeripheral Arterial Disease and neuropathy,xix andthat surgery reduces long-term mortality byaround a third.xx

The average cost of treating one of thesepatients’ diabetes is around £3,717 per annum.The cost of performing bariatric surgery is around£6,000. The cost of one year of diabetestreatment and one episode of surgery is £9,717,whereas the cost of three years of diabetestreatment - bearing in mind this would continuefor many years - is £11,151. It does not, therefore,take much time before the surgery becomes costneutral.

In Birmingham, for example, there are 1,852patients with Type 2 diabetes who would qualify, and we could expect around 1,111 of thesepatients to show no indication of diabetes oneyear after surgery. The savings would quickly addup.

This is an example of how the treatment of anexisting condition can lead to very large savingsfurther down the line.

What is the cost of not doing something?

In a submission to this inquiry, the Obesity HealthAlliance (OHA), a coalition of 43 medical colleges,patient groups and charities, noted that “Figuresconsistently show a widening equality gap withobesity more prevalent in the most deprivedchildren and adults.” It is a duty incumbent ongovernment to acknowledge this is a loomingsocial justice issue, and to begin forming anational overarching strategy to tackle theproblem.

Alongside the social cost, if prevention andtreatment services are not appropriately funded,people with morbid obesity will continue topresent a huge ongoing cost to the system formany years to come. Our obesogenicenvironment “consistently promotes and pushespeople towards unhealthy choices”, according tothe OHA, and while moves to address thischallenge are welcome, morbid obesity has manycomplex causes. Only through providing help andsupport through services which adequatelyrecognise this complex causation will we be ableto bring down the cost to future generations, bothin financial and wellbeing terms.

The argument for intervening earlier andsupporting the proliferation of Tier 3 services isclear. They are effective in tackling complexcases of obesity, which provides an opportunityto reduce costs in the future before the costly co-morbidities set in.

The Government should commission or supportthe development of a thorough, peer-reviewedcost benefit analysis of earlier intervention andtreatment of patients with obesity. This shouldinclude an analysis of the impact on work, earning capacity, mental health and system finances. Itshould be independent work conducted by amajor academic institution to avoid politicallycharged media coverage.

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60% of patients with diabetes who receive bariatric surgery then go into remission

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Developing a national obesity strategy

The Royal College of Physicians, in theirsubmission of evidence to the inquiry, noted thatthe transfer of commissioning responsibility fromNHS England to CCGs has led to furtherinconsistencies and regional variability in deliveryof the essential service. CCGs are able to issuetheir own obesity treatment strategies meaningthat access to treatments depend not on theclinical needs of patients but on theirgeographical location.

An audit by this APPG of the draft plans publishedby Sustainability and Transformation Partnershipsfound that around a third of plans did not haveany detail on how obesity would be tackled inthat footprint.

The APPG believes that the lack of consistentprovision across the country - with patches ofgood practice dotted around the country and notalways invested in effectively – must be tackled.

The Government’s Childhood Obesity Strategy,which set out a ten-year plan to tackle childhoodobesity through encouraging healthier choicesand the reformulation of soft drinks, was awelcome intervention into the national debate.The APPG believes that there should be anambitious national plan for tackling adulthoodobesity, and there should be clear achievableasks.

This report has set out that people with obesityare less likely to be in work, often sufferdiscrimination, and are more likely to suffer fromfurther health problems such as diabetes, someforms of cancer, and cardiovascular disease.Obesity can also have an impact on mental healthand wellbeing. All of these conditions have directand indirect healthcare costs, including socialcare, and an impact on productivity, wellbeingand the nation’s finances.

While it is unrealistic to prevent and treat alladulthood obesity, the financial argument is verymuch there for a renewed focus on makingequitable and appropriate provision across thewhole obesity pathway, which a national obesitystrategy can set out. The strategy could be co-ordinated by the Cabinet Office and bring in theDepartment of Health and Social Care (and itsexecutive agencies); Ministry of Housing,Communities and Local Government; Departmentfor Transport; Department for Environment, Foodand Rural Affairs; and Department of Digital,Culture, Media and Sport.

This national strategy should set out the minimumlevel of access to services expected in anylocality. It should review services which aredeemed “best practice”, and look at how theseservices can be replicated across the country andbrought into a best practice pathway for obesityservices within the UK.

■ A national obesity strategy for both adult andchildhood obesity should be developed andimplemented by the Government.

■ The Government should commission or supportthe development of a thorough, peer-reviewedcost benefit analysis.

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About the service: The Rotherham Institutefor Obesity (RIO) was established by Dr MattCapehorn, who served as its ClinicalManager. It was established in 2009 as partof the development of the Rotherham HealthyWeight Framework, which was created with£3.5m of funding for a three-year pilot.Referrals came from all GP practices in theRotherham area.

How it worked: The RIO multidisciplinaryteam (MDT) was made up of several specialistindividuals who have distinct roles, but whichwork together and have regular consultationswith the patient. Each care pathway isdifferent depending on the patient.

Following referral, the patient has acomprehensive consultation, weighing andmeasuring, and visits the obesity specialistnurse to review the history of their weightproblem. Some will be seen by Dr Capehorn,who can assess whether weight losspharmacotherapy or other treatment isneeded. The service has specialist equipmentfor both adults and children in the on-sitegym, which is offered alongside care such astalking therapies.

What was the impact? Throughout 2010 and2011, 3,325 patients were referred to theservice, of which 49% completed the full six-month programme. 1,087 patients met theirNHS Rotherham weight loss targets and ofthese, one in five lost at least 10% of theirbody weight. The average weight loss wasaround 5% amongst all completers. Whilstcommissioned as an NHS service, thecumulative weight loss due to the Tier 3service (RIO) alone was 33.7 metric tonnes,demonstrating the impact that can be madeat a local population level.

The problem: Following 2014 changes, whichhanded responsibility for Tier 3 services toCCGs, RIO lost its NHS funding and nowoperates as a private service. In 2014,Diabetes UK said, ‘The success of theRotherham Health Weight Framework showsthat investing in a comprehensive carepathway for obesity, involving community andspecialist services, has benefits for patientsand can save money in the long term.’ Thatservices such as RIO cannot survive as NHScommissioned services in this environmentsuggests that a national long-term approachis required.

There is now no dedicated weightmanagement service provision for adults.

The total cost of all of the Tiers ofinterventions, for both children and adults(excluding adult Tier 4, which was initiallycommissioned via specialist commissioning,and then via NHS England, and more recentlyafter April 2017 by the CCG) was less than£1m. This was to cover a population ofapproximately 260,000.

If this was scaled up, then an area ofapproximately one million people could havecomprehensive weight managementservices, like Rotherham did, for less than£4m per year.

If scaled up further, the whole nation couldhave comprehensive weight managementservices for less than £240m per year - whichis significantly less than the estimated£49.9bn per year that direct and indirect costsof obesity are expected to cost the NHS byas soon as 2050.

Case study: Rotherham Institute for Obesity

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About the service: Dr Carly Hughes, aGeneral Practitioner in Norfolk specialisingin obesity, runs the Fakenham WeightManagement Service (FWMS). It was startedin 2011 by Dr Hughes, and anendocrinologist and public health consultant.

How it worked: Individuals who present atprimary care with a BMI of over 30kg/m2 areinitially referred to a Tier 2 service forlifestyle interventions. People with BMI >35kg/m2 and co-morbidities are then referredto Tier 3 service. Everybody with a BMI ofover 50kg/m2 is referred directly to the Tier3 service. Around 450 patients are referredannually to the service. Tier 3 patients arethe most complex, and have often failed tomaintain weight loss with Tier 2 services.

The Tier 3 service adheres to NICE CG189,and conducts specialist investigations

through a comprehensive team including abariatric physician, dietician, mental healthspecialist, physiotherapist, health trainer, andspecialist nurse. It may also include abariatric surgeon if co-located with thesurgical unit. The team is able to provide amixture of individual and group interventionswith a high degree of patient participation,incorporating dietary and physical activityadvice and pharmacological andpsychological interventions. The protocolsare shared with the Norfolk & NorwichUniversity Hospital Trust, Luton & Dunstable,and UCLH bariatric surgery units.

What was the impact? In a 2014 study of theprogramme’s results, the mean weight losswas 10.2 kg among the participants whocompleted the 12-month programme. Onequarter of all completers left the programmehaving lost at least 10% of their initial weight.

Case study: Fakenham Weight Management Service

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This report has demonstrated that the causes ofobesity are many and are complex – but that thesystem set up to prevent obesity from developingin childhood and adulthood, and which isdesigned to treat obesity amongst those witheasily rectified problems and more complexcases, is inadequate.

In childhood, children are exposed to pervasiveadvertising for deeply unhealthy foods. Inadulthood, those with lifelong obesity or excessweight cannot access the multidisciplinaryservices they need toimprove their health. Evenwhere services are available, access isinconsistent across geographical boundaries.Evidence-based NICE guidance regardingbariatric surgery is also not being implemented. This is deeply counterproductive given thedemonstrable savings which can be gained fromthe application of the right preventative measuresand the right treatment at the right time. Allowingproblems to escalate helps nobody.

A whole system approach is needed at both thenational and local level. Few aspects ofgovernment are exempt from needing to payattention to this looming issue.

We must also acknowledge the voices of thosepeople with obesity who responded to thisinquiry. Their stories of being pushed back fortreatment, of being rejected for jobs, and offruitlessly battling to lose weight and save theirown health are a lesson to us all that obesitypolicy must set out what will be done to helpthose who already live with obesity, as well asthose who will develop it in the future.

It is hoped the Government takes note of therecommendations set out in this report. This way,we will be able to take a big step forward in thefight against this destructive condition.

Conclusion

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i Link: https://www.local.gov.uk/making-obesity-everybodys-business-whole-systems-approach-obesity ii http://researchbriefings.files.parliament.uk/documents/SN03336/SN03336.pdfiii Flint SW, Hudson J, Lavallee D. UK adults’ implicit and explicit attitudes towards obesity: a cross-sectional

study. BMC obesity. 2015 Dec;2(1):31.iv Flint SW, Čadek M, Codreanu SC, Ivić V, Zomer C, Gomoiu A. Obesity discrimination in the recruitment

process:“You’re Not Hired!”. Frontiers in psychology. 2016 May 3;7:647.v Flint SW, Reale S. Weight stigma in frequent exercisers: overt, demeaning and condescending. Journal of

health psychology. 2018 Apr;23(5):710-9.vi Vartanian LR, Novak SA. Internalized societal attitudes moderate the impact of weight stigma on

avoidance of exercise. Obesity. 2011 Apr 1;19(4):757-62.vii Flint SW, Čadek M, Codreanu SC, Ivić V, Zomer C, Gomoiu A. Obesity discrimination in the recruitment

process:“You’re Not Hired!”. Frontiers in psychology. 2016 May 3;7:647.viii Flint SW, Nobles J, Gately P, Sahota P. Weight stigma and discrimination: a call to the media. The Lancet

Diabetes & Endocrinology. 2018 Mar 1;6(3):169-70.ix Diabetes: Facts and Stats 07 Part Two: Who is at Risk Of Diabetes?, Diabetes UK, March 2015, pg.7. x http://www.adph.org.uk/wp-content/uploads/2017/11/ADPH-Policy-Position-Obesity.pdf xi NB: 88% of Local Authorities and 91% of CCGs responded: Getting the measure of obesity: Weight

management service provision in England, Novo Nordisk, Spring 2018.xii Getting the measure of obesity: Weight management service provision in England, Novo Nordisk, Spring

2018. xiii Getting the measure of obesity: Weight management service provision in England, Novo Nordisk, Spring

2018, pg.10.xiv Submission by the British Medical Association to the All-Party Parliamentary Group on Obesity’s 2018

inquiry.xv Getting the measure of obesity: Weight management service provision in England, Novo Nordisk, Spring

2018, pg.14.xvi Bariatric surgery for obesity and metabolic conditions in adults, David E Arterburn & Anita P Courcoulas

et al, British Medical Journal, 2014: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707708/ xvii https://www.nhs.uk/conditions/weight-loss-surgery/ xviii Diabetes expenditure, burden of disease and management in 5 EU countries, Panos Kanavos, Stacey

van den Aardweg and Willemien Schurer, London School of Economics, January 2012.

References

ALL-PARTYPARLIAMENTARY

GROUP ON OBESITY

Making effectiveprevention and

treatment of obesity apriority and a reality

www.ObesityAPPG.com@ObesityAPPG

[email protected]

the current landscape of obesity services€¦ · 3 the all-party parliamentary group on obesity 4...

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