Examination of Witnesses (Questions 1040-1059)
18 DECEMBER 2003
DR IAN
CAMPBELL, DR
COLIN WAINE,
DR NICK
FINER, PROFESSOR
JOHN BAXTER
AND MS
DYMPNA PEARSON
Q1040 Dr Naysmith: How about the national
service framework? I keep hearing that question, but if we have
too many national service frameworks, then—
Dr Waine: We have had national
service frameworks for heart disease and for diabetes; yet at
the heart of both of them is the problem of obesity; so surely
it would be better to tackle the root causes than the end results.
Dr Finer: A national service framework
would go a long way to addressing the issue of focusing on obesity
as a disease, and the very clear evidence that weight loss can
reverse those disease processes. That lies at the heart of a national
service; not just to recognise this, but to know that there are
interventions and treatments that can and should be provided,
which would alter the course of the disease and improve the health
status of patients. The problem at the moment is that although
there are odd little lines in the existing NSF to cardiology and
diabetes, the fact that they are right down in the sub-sub-sections,
means that to all intents and purposes they are ignored. The other
reason an NSF would be extremely important is that up until now
virtually the only focus of the health service has been in terms
of prevention, which is of course terribly important. The fact
is, we cannot completely or at the moment we can hardly prevent
obesity. We are failing, so there has to be some recognition by
the health service that it has an obligation and the duty and
possibility to treat obesity where prevention has failed.
Ms Pearson: I completely agree
with those points. My recent experience of working with doctors
and nurses is that over the last five years there has been an
increasing interest in obesity management. Suddenly, there has
been this sense of hopelessness, due to the recent GMS contract,
which puts a very, very low priority on obesity management. I
think we need to be aware of that.
Q1041 Dr Naysmith: So you are in favour
of a national service framework.
Ms Pearson: Absolutely.
Dr Campbell: The impact of a national
service framework should not be underestimated within the world
of general practice. The National Institute for Clinical Excellence
has made many pronouncements on weight management and the use
of drugs for surgery, but they are only accepted at a distance
by health authorities and not always acted upon; whereas national
service frameworks are accepted as being directives that must
be done, by which primary care services are judged; so it would
have a huge impact on the service that followed.
Professor Baxter: I wanted to
reiterate what has been said already. From the standpoint of my
society, the surgery of obesity, which only affects a small sub-set
of those with obesity, to see where surgery fits into a national
service framework would be extremely important. It never ceases
to amaze me how little the doctors know about obesity who refer
patients to me. I am thinking particularly in primary care. The
whole thing is not joined up. People do not understand the success
you can have with surgery and where it fits into the overall framework
for those people that need that sort of treatment, so I am highly
in favour of an integrated framework.
Q1042 Dr Naysmith: We will return to
the question of surgery and its place in treatment in a few minutes
so we will leave that for the moment. There are a couple of other
questions I would like to ask. Is obesity a curable condition?
That is an interesting concept. Clearly, there is a mismatch between
need and availability of services. If we are going to do something
about it, do you think child obesity should be the primary target
at this stage, or can we do it in an overall way?
Dr Finer: It is as curable as
diabetes and osteoporosis and heart disease, and just as incurable
as those diseases. The idea that one can cure a chronic disease
is not a helpful model. It is a matter of controlling, ameliorating
and decreasing the health burden to the individual and to society.
There is very clear evidence that in that respect obesity falls
right into the same category of diseases as other chronic diseases—better
than some in terms of manageability, curability, but worse than
others. In terms of childhood/adolescent obesity, the problem
there is that we have much less information and much less of an
evidence base to know how effective our treatments will be at,
prevention, let alone cure; but clearly in terms of potential
health gain, they are an absolutely vital part of the group of
people that we need to treat. All of us here are primarily doctors
treating adults; the very fact that there is virtually no paediatric
or adolescent treatment available speaks volumes.
Q1043 Dr Naysmith: The question carries
the connotation that you have probably lost the battle for many
older and middle-aged people; and if we are going to get to grips
with this crisis that is developing, we need to start with younger
people.
Dr Finer: I would disagree with
that. There is very clear evidence that there are huge health
gains from treatment of adults. That treatment is not just measured
in terms of weight loss. One of the issues is that we should not
be looking at obesity treatment just in terms of how many pounds
are lost; it is a complex intervention that addresses a whole
variety of risk factors and associated disease managements.
Dr Waine: You do not die of diabetes;
you usually die of one of the many complicating factors like heart
disease. The great news that has come out of obesity research
is that relatively modest weight losses of 5-10% can hugely reduce
people's risk factors for these other conditions. It is some sort
of metabolic health that you are aiming for, not ideal body weight—which
might be termed a cure. We do not need to go as far as that. What
we are looking for is much more achievable.
Q1044 Dr Naysmith: And the question of
starting young?
Dr Waine: Undoubtedly. The relentless
rise of childhood obesity means that whilst you cannot ignore
the adults, these people have their lives ahead of them, so you
have got to get in there quickly.
Ms Pearson: The benefits of small
amounts of weight loss has made a huge impression upon practitioners
and patients alike, when they realise they are not being expected
necessarily to get down to ideal weight. That is a very important
message to get across. With regard to children, we need to remember
that approaches for children need to be directed towards families.
The children cannot manage their weight on their own, so you cannot
isolate children from the family picture. Approaches need to be
directed towards children, but bearing in mind that the role models
for children are the parents of today.
Q1045 Dr Naysmith: We have found evidence
that obese adults tend to have obese children.
Ms Pearson: Absolutely.
Q1046 Dr Naysmith: Not always, of course.
Ms Pearson: Not always, but it
is a contributing factor, and so the environment that the child
lives in needs to be addressed.
Dr Campbell: Whilst no-one would
disagree that it is important to prevent obesity, particularly
among children, I just find it inconceivable that we should reach
a situation where we are not able to offer treatment to those
who are already obese, which is about 10 million people. For those
of us working at the coalface, so to speak, the perceivable measurable
benefits of even modest weight loss; and to see the response in
a patient who has worked towards achieving some long-term weight
loss is rewarding to them and the clinician; and you can see the
medical benefit. I could not conceive telling them that the emphasis
was entirely on prevention and that they were past help.
Q1047 Dr Taylor: Dr Finer, it was your
memorandum that impressed upon all of us the tremendous stresses
that exist in obesity services. Can you give us an idea of the
effect of waiting-list targets on your practice?
Dr Finer: I run clinics both at
Addenbrooke's Hospital and at Luton & Dunstable Hospital.
The problem has always been how to meet the demand which is there,
with the lack of resources. At Luton, where I worked until a year
ago and ran a clinic once a fortnight there, over the last seven
or eight years the only way of managing referrals was to shut
the clinic to referrals. It was shut for three or four years out
of the last eight years. The reason for shutting referrals was
when waiting lists went beyond the one year. I felt that it was
useless and actually counterproductive. I have been at Addenbrooke's
now full-time for a year, and I run a clinic that is primarily
resourced from my appointment as a university appointment. The
clinic there, as you have seen from the figures receives an increasing
number of referrals. Without my doing a large number of extra
clinics to see these new patients, I would have lost Addenbrooke's
Hospital its third star probably six months ago. The problem them
comes that even if you see the new patients you do not have any
capacity for managing them. The only answer, it seems to me, to
this is that you either have to get resources to match the demand,
or you have to restrict the referrals to the capacity of the clinic,
or you lose the clinic. All three of those options are being actively
considered at Addenbrooke's by myself and the managers.
Q1048 Dr Taylor: How do your large group
clinics work? I think you say up to 35 people at a time.
Dr Finer: This was an emergency
measure in order to try and meet the recent 17-week waiting-list
target, and that soon goes down to 12 weeks. It is, I think, an
inappropriate way; and having run two of these joint clinics where
all new referrals over a 12-week period are invited to come to
a mass group new clinic, I think it is not an acceptable way of
caring for people with disease. That is what led to, if you like,
this document to highlight the problems to the Trust.
Q1049 Dr Taylor: Who made it clear to
you that you were going to lose Addenbrooke's their three stars?
Dr Finer: That is probably my
own interpretation. My understanding is that a very small number
of breaches of the waiting-list targets is one of the key measures
for star status; and there is enormous pressure upon clinicians
not to allow that to happen. So on a regular basis, once every
week or ten days, I would be being asked by managers, could I
see this patient, that patient, a few more patients, because otherwise
we would be breaching it.
Q1050 Dr Taylor: In your recommendations
you say: "Obesity medicine could become a sub-specialty of
metabolic medicine, diabetes and endocrinology or even cardiology."
Is that a more practical solution than trying to form a separate
specialty for obesity itself?
Dr Finer: I think this is a very
difficult issue. Clearly, specialties are within the remit/control
of the Royal Colleges, and to devise a specialist training just
in obesity medicine, however desirable it might be, is unlikely
to happen and unrealistic. The question then is, if we are going
to develop secondary/ tertiary care services, who is going to
do it? The logic is that it would fit in to metabolic medicine,
but I think that should not preclude cardiologists, for example,
being involved. In Europe there are very clear examples of cardiologists
who have developed and run obesity services. In Canada there are
posts in cardiological obesity medicine; so I think that if we
were to develop this we need to be open-minded and broad-minded.
I said in my evidence that every hospital now requires to have
somebody who is designated to lead on these services.
Q1051 Dr Taylor: Where obesity clinics
exist at the moment, what do you think is the typical sort of
waiting time? Is it 12 months, like yours?
Dr Finer: Yes, or at least 12
months. Most clinics operate some sort of rationing system in
terms of either screening, setting barriers to referral—and
the biggest barrier in screening used to be the waiting-list.
Q1052 Chairman: I am interested in this
kind of bulk provision you are doing, which some would see as
an innovative approach to the waiting-list problem. How would
you approach a session of that nature? Is it more of an educational
session, a wider session, with you talking about the management
of obesity and diet? What do you deal with in these sessions?
Dr Finer: The background to this
is that at my other clinic at Luton for many years we have run
a system whereby we have an evaluation of patients by a nurse
specialist, and an evaluation by means of a quite complex questionnaire
to look at expectations, motivations and needs. That is a very
time-consuming process because you are sending things out by post
and people are coming and going, and I do not have those resources
at Addenbrooke's. The patients are forewarned that this is what
will be happening. They have their height, weight and blood pressure
measured, and they have blood samples taken for screening for
diseases. They are then give a 15-minute talk by myself to describe
what treatments and management of obesity entails. They are then
asked to complete fairly detailed questionnaires; and, based on
those, I try and make evaluations for those patients I can best
provide the resources that I have to, and for others, suggestions
back to primary care, as to the interventions that their referring
doctor might undertake.
Q1053 Chairman: There is no resistance
by patients to this kind of approach as far as you are aware.
Dr Finer: It is not popular. They
feel cheated. They have been referred to a hospital specialist,
and they do not see a doctor, except standing up to give an introduction
to the progress.
Q1054 Chairman: They understand why you
are doing this.
Dr Finer: They understand why.
It is a crisis measure, which is driven not by clinical need but
my managerial requirements.
Q1055 Dr Taylor: After such a clinic,
when you have seen 35 patients, do you then do 35 individual letters
to their GPs?
Dr Finer: Yes.
Ms Pearson: I would agree there
is a need for better specialist services in place, but part of
the reason that the specialist services have been inundated is
that there are not adequate services within the primary care setting.
One of the things we need to remember about obesity is that it
is a very complex condition to treat, and there is no simple answer.
People who are overweight, or who have medical complications as
a result of their obesity need to have some kind of individual
assessment, and I would argue that that can happen in primary
care. Then, those who need specialist care services can be directed
to NHS interventions or non-NHS interventions; so primary care
is where the big gap is.
Q1056 Mr Jones: Apart from the way you
perceive these things, is there any evidence that the mass consultation
produces worse results than individual consultation?
Dr Finer: I do not have sufficient
experience to be able to report on that. It would also be true
that the process itself leads to a management process that is
inherently different to a traditional medical model of a one-to-one
consultation/evaluation/assessment. Of the 35 patients I see,
I may end up only recalling to the clinic 10 of such patients.
There may be other patients who require obesity surgery, which
we are not funded to provided; so it seems to me very little point
in bringing those patients back if I cannot provide them a treatment
that it is fairly clear would be high on the priorities. Similarly,
there may be patients who have not received what I would regard
as adequate or appropriate interventions within primary care,
so we would suggest that those take place.
Q1057 Mr Jones: These are all subjective;
there is no evidence. It may well be that what you are now doing,
that you do not particularly like, is extremely cost-effective.
Dr Finer: It could be cost-effective,
but it is resourced at the moment out of primarily my academic
time, because it does involve a large amount of administrative
superstructure, which would need to be resourced. I would not
like to say it is entirely not evidence-based; we have audited
and evaluated clinical interventions, and try to derive predictors,
both positive and negative, with different modalities of treatment;
and some of that audit experience is applied back to the process
of selecting patients for certain treatment programmes.
Q1058 Mr Bradley: If we could return
to surgery, Professor Baxter, in your memorandum you calculate
that about 1.2 million people could be eligible for bariatric
surgery under the NICE guidelines, but currently only 200-300
procedures are undertaken. How would you tackle that massive disparity
in those numbers, and can you give more information around that
calculation of 1.2 million? Do all those 1.2 million want that
intervention?
Professor Baxter: That calculation
is not mine; it is the National Institute for Clinical Excellence,
which just simply looked at the population base—the number
of adults—looked at the figures for the incidence of morbid
obesity—0.8% of males and almost 2% of females; and then
worked out how many people would be morbidly obese, without getting
bogged down with definitions. They then made an assumption that
if you asked 100 of them how many would want surgery, only 5%
would, which is an extremely conservative estimate. That is where
the number comes from. This is an enormously difficult problem,
because, as you know, we are third world with respect to obesity
surgical services, when compared to other OECD countries, Australasia,
America and so on. I think that because the Health Service has
struggled for years to deliver reasonable services for emergencies,
cancer and other things, obesity surgery has just been forgotten,
and it has become unfashionable. Now, it is being re-discovered,
along with advances particularly in the keyhole surgery, the laparoscopic
area. Most obesity surgery in the next three or four years will
be converted entirely to keyhole surgery, which reduces a lot
of morbidity, and is a lot more acceptable for both surgeons and
patients all round. Because this has reared its head again, the
service that is provided is very much postcode, as you see in
my briefing paper. It has just grown up around areas of interest,
where there has been a surgeon who has taken an interest in the
surgery and tried to develop it, usually against great problems
with their local trust, which invariably sees it as a new service.
It is not really a new service; it has just been a re-discovered
service; but it is seen as a new service, and its logistic tail
is that it needs a multi-disciplinary team that needs special
beds, special operating tables and new equipment, at a time when
most trusts are struggling to meet other targets. That is why
we have such a patchy service at present. NICE, as you well know,
has come out and said there should be more obesity surgery because
it is effective in properly-selected patients, and strategic health
authorities are now starting to panic about how to provide this
service. There is not enough trained surgeons, as you can see
in my briefing paper—there are only 13 or 14 in the whole
country, when we should have 300 as a minimum, maybe more. The
NHS does not have the capacity, if they start doing this type
of surgery, if an upper GI surgeon trains to do this, then he
has to give up doing something else. It is the typical problem
we have, that it needs a strategic plan to build it up, as NICE
suggested; but there is no strategic direction; nobody is running
with this ball; nobody is asking how we are going to model it
and do it.
Q1059 Mr Bradley: As technology develops,
moving towards more keyhole surgery, does that mean it could move
towards day-case intervention, as opposed to in-patient, with
all the costs involved in that?
Mr Baxter: Yes. About half the
procedures, particularly the new device called gastric banding,
which is getting quite popular, and there is good evidence that
it is an effective treatment—in many centres round the world,
they are done as day cases; or certainly an overnight stay at
the most. I do them as day cases myself. Other types of surgery
that are more complex would be in hospital two or three days,
as opposed to seven or ten days in the old days with open surgery.
The technology is helping for a faster turnover.
Ms Pearson: To pick up on the
point about multi-disciplinary teams, we had a meeting just last
week of dieticians across the country who are involved in obesity
surgery clinics, and grave concerns were expressed there about
the lack of involvement of dieticians. Often, these surgeries
are happening without the dietetic resource being there. Also,
there are very long-term implications in terms of nutrition, which
need to be picked up by dieticians working in the community; so
the funding needs to follow the surgery as well.
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