Memorandum by Dr Nick Finer (OB 104)
I am currently a Senior Research Associate at
Cambridge University, and Honorary Consultant in Obesity Medicine
at Addenbrooke's Hospital, Cambridge. I was Chairman of the UK
Association for the Study of Obesity from 1993-1996, am a member
of the Royal College of Physicians Committee on Nutrition and
am a registered nutritionist. I have published more than 70 scientific
papers and contributed to 12 books on obesity and nutrition. I
have developed and led clinics for obesity treatment at both Addenbrooke's
Hospital (a teaching hospital linked to Cambridge University,
my main appointment) and Luton and Dunstable Hospital (a District
General Hospital where I hold an honorary appointment). Clinics
at these two centres provide specialist assessment and management
to NHS patients referred either by their primary care physician
or from other secondary care centres. The clinics offer multidisciplinary
care involving physicians, surgeons, dietitians, specialist nurses,
clinical psychologists and exercise specialists. The existence
and future of these clinics has always been dependent upon research
funding, and both continue to struggle to receive explicit funding
from Primary Care Trusts.
I have contributed to the Royal College of Physicians,
UK Association for the Study of Obesity and the Counterweight
Programme submissions to your Committee, and would therefore like
to concentrate this submission on the contribution of secondary
and tertiary care centres within the NHS to the management of
obesity (terms of reference bullet points 4,5 and 6).
4. WHAT CAN
BE DONE
ABOUT IT?
Even the most successful prevention policies
cannot address the current burden of ill health related to obesity,
nor obviate the need now, or in the future, for appropriate medical
care for the obese. While initial management can, and should,
take place in primary care, it is inevitable that there exist
many patients with severe and complex problems relating to their
obesity who require specialist assessment and treatment. These
include, for example, patients with metabolic and cardiovascular
disease whose treatment will need to involve a holistic approach
to their medical needs; sleep apnoea syndrome; peri-operative
care where weight loss may be needed to minimise risk and optimise
outcome, and life threatening morbid obesity.
Research has already identified that the outcome
of existing drug treatment is enhanced by skilled and comprehensive
lifestyle interventions and support, which are most likely to
be deliverable in the multidisciplinary setting of secondary care.
It seems likely that identification of individuals with genetic
causes for their obesity will become a clinical reality and may
help target appropriate choices from an increasing range of pharmaceutical
interventions. Specialist skill experience in the use of such
drugs, and drug combinations is likely. The role for secondary
care to develop, and then inform and support primary care in new
therapeutic areas of medicine continues to be an appropriate model
for most diseases; obesity is no different. There is a need to
develop such a network within health care to address the current
and future burden of disease and ensure that best practice is
promulgated and supported.
5. ARE THE
INSTITUTIONAL STRUCTURES
IN PLACE
TO DELIVER
AN IMPROVEMENT?
The answer to this is "No". Primary
care focuses mainly on prevention. Secondary care cannot effectively
contribute to the management of obesity since it hardly exists.
Lack of access to care for patients with obesity
The current prevalence of obesity means that
within the catchments area of a typical hospital serving a population
of 300,000, about 130,000 adults will be overweight or obese,
53,000 obese (BMI>30), and about 3,500 morbidly obese (BMI>40).
The Association for the Study of Obesity is aware of 9 specialist
clinics for the treatment of obesity within the UK. There exists
a lottery between areas with no specialist clinics, and even within
those areas which do have specialist clinics which have severely
limited capacity. At Luton my clinic capacity is to see about
250 new patients a year. At Addenbrooke's capacity is 80 new patients
a year, about fifth of current referrals. Paradoxically, waiting
list targets, which cannot be met in such circumstances, now threaten
the continuation of these services. Thus the vast majority of
patients with obesity have no access to specialist care for their
disease, despite the fact that it is a disease that shortens life,
is the main cause for diabetes, impairs quality of life, and has
serious financial consequences for the National Health Service
(NHS) and for the economy.
Lack of provision of care for patients with obesity
Services for morbid obesity were defined in
the Specialised Services National Definitions Set (2nd Edition)
No. 35 released by the Department of Health in December 2002.
These identified specialised treatment activity that should be
subject to collaborative commissioning arrangements including:
"an integral management approach . . . aimed at weight loss
and weight maintenance, . . . drawn up by a multi-disciplinary
team to meet the needs and requirements of each individual patient."
In Anglia, and I believe elsewhere in the UK, these services remain
unimplemented, with no process or individual responsible for their
implementation as yet operational.
The National Institute for Clinical Excellence
issued guidance in Report 46, published in July 2002. They recommended
that ". . . surgery to aid weight loss should be available
as a treatment option for people with morbid obesity" and
concluded that "The guidance is clear that people with morbid
obesity who are considering surgery to aid weight loss should
discuss the treatment with the specialist responsible for their
treatment". Despite this, obesity surgery remains virtually
unfunded and unavailable to most eligible patients through the
failure of District Health Authorities and now Primary Care Trusts
to implement NICE guidance.
Even in those established clinics, there is
rarely a full complement of staff to form the recommended multidisciplinary
teams of dietitians, exercise counsellors, psychologists etc.
The above describes the situation for adult obesity; services
are even patchier for adolescents and children.
6. RECOMMENDATIONS
FOR NATIONAL
AND LOCAL
STRATEGY
Development of physicians specialising in obesity.
No recognised training or speciality of "obesity
medicine" currently exists; it is needed. Every hospital
should have an identified clinician with skills, responsibility,
and resources for implementing existing knowledge about obesity
and its treatment across traditional specialties (eg diabetes,
cardiology, gynaecology, orthopaedics and so on) to foster the
concept of "nutrition-centered" hospital care. Obesity
medicine could become a sub-specialty of metabolic medicine, diabetes
and endocrinology, or even cardiology. It is however unlikely
that this can happen until a specialist service exists and is
resourced. The obesity specialist physician would be expected
to interface with primary care along models developed for the
delivery of care for diabetes and ischaemic heart disease, as
well as drive the provision of evidence-based interventions for
more complex patients. This approach is well described in Specialised
Services National Definitions Set (2nd Edition) No. 35 (Obesity).
An obesity physician would ideally be trained to treat children
and adolescents as well as adults; this would facilitate treatment
of families rather than individuals within the family. Obesity
physicians might be seen as "team leaders" for co-ordinating
multi-disciplinary approaches to obesity treatment that will involve
dietitians, exercise therapists, specialist nurses psychologists
and counselling staff, as well as engaging in community-based
prevention.
Implementation of existing Department of Health
Policy for provision of specialised services
There is an urgent need to develop the infrastructure
and revenue to support care for patients with morbid obesity and
allow implementation of NICE guidance 46 and implement Specialised
Services National Definitions Set (2nd Edition) No. 35 (Obesity).
There is a need to resource clinics to meet
NICE guidance on the use of existing drugs.
There is a need for resources that will include
specialist care to meet National Service Framework standards on
obesity for diabetes and coronary heart disease.
Support and Integration of Clinical Obesity Research
Research is needed to translate the rapidly
increasing knowledge on the causes of obesity and its complications
into effective treatment. There will be a growing need for specialised
assessment of children and adolescents with obesity, which will
increasingly involve screening for genetic mutations and susceptibilities.
Many new drug targets have been identified with
the likelihood of new classes of drugs for the treatment of obesity
becoming available over the next decade. There will be a need
for clinical research to clarify their place in obesity management,
and, for example, develop and evaluate safe and effective drug
combinations. The National NHS Research and Development Programme
has a responsibility to support such translational and operational
research through its Health Technology Assessment, Service Delivery
and Organisation, and New & Emerging Applications of Technology.
December 2003
Annex X
OBESITY
SERVICE ISSUES
INTRODUCTION
The need to tackle the growing trend of obesity
in the UK is highlighted in the NSFs for Diabetes and CHD as obesity
is a major factor in the onset of both these conditions as well
being a major cause of premature death.
The outpatient obesity service is provided by
Dr Nick Finer who is based in the CRF and contributes one clinic
session every two weeks. This activity generates income for the
Trust even though this service is not NHS funded. Dr Finer has
been willing to provide this service for the Trust as it provides
a valuable service to the local population in addition to aiding
his identification of suitable patients for his research projects.
However, at this time the NHS workload is increasing in spite
of never having "advertised" this service to GPs. The
clinic now needs to be funded to run weekly otherwise waiting
time targets will be breached and clinical care will be compromised,
or alternatively the clinic will need to become a research clinic
that will not accept referrals from GPs unless the patient meets
research criteria.
ACTIVITY
The activity of the obesity clinic has escalated
(shown below). The number of new patients seen by the end of October
2003 has already exceeded the total for the year 2002-03.
Although the actual figure per month is quite
variable, the trend line shows that by October 2004 there will
be around 45 patients per month being seen in this clinic. However,
this trend line may well be underestimating the true number.
If the number of new patients seen is analysed,
it shows that the number has increased dramatically in the last
year. This will have a knock on effect on the number of return
patients and as a consequence the trend line above is likely to
be underestimating the number of patients that will need to be
seen in the obesity clinic.
This forecasts that 160 new patients will be
seen in 2004-0; with a new-follow up ratio of 1:4.3 (2002-03 data),
then a total of 848 patients will be seen in clinic—a rate
of over 70 per month. This is clearly impossible with a two-weekly
clinic and current resources.
Options if no additional funding is available
in 2004-05
— Withdraw from providing an NHS service
and operate the clinic as a research facility only—to see
patients that are referred and meet research criteria.
— Set more rigorous criteria for the
clinics and only accept referrals that meet these criteria.
Options if funding is made available in 2004-05
The options available clearly depend on the
level of funding. However, if the LDP bid for a Specialist Nurse
and dietetic support is funded:
— Run a weekly clinic to manage the
increasing demand. However, the demand will need to be closely
monitored to ensure that it does not continue to outstrip capacity.
If this occurs then more rigorous referral criteria may still
need to be set.
— Use the Specialist Nurse in a combined
role to support clinics but also to provide input into primary
care. The primary care aspect would be to provide education to
GPs and Practice Nurses and to help set up primary care obesity
clinics. The Specialist Nurse could then be the "gatekeeper"
for referrals into secondary care. This would achieve the double
benefit of improving obesity management within primary care and
managing the referrals to secondary care more effectively.
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