Select Committee on Health Minutes of Evidence


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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