Health and Social Care Bill

Memorandum submitted by Weight Watchers UK Limited (HS 82)

Summary

· Tackling obesity is the number one public health priority – yet omitted from the Health and Social Care Bill

· Responsibility for commissioning of weight management services for the public remains unclear

· How will weight management services for the public be commissioned?

· GP consortia will need training and support in commissioning weight management services

· Danger that GPs will only commission services for the severely obese – when earlier intervention at lower BMIs more likely to be effective

· No evidence that NHS reforms will solve the current inequalities in patient access to effective, evidence-based weight management services

· Will the Health and Social Care Bill level the playing field between NHS and non NHS providers of weight management services to focus on outcomes?

· Weight Watchers welcomes judgement of services based on outcomes

· Payment by results may affect equity of access to services

· Weight Watchers recommends an approved providers list of weight management services

· Weight Watchers is proven to deliver effective and cost-effective interventions

1. Tackling obesity is the number one public health priority

Being a healthy weight is central to good health. Being overweight or obese has a severe impact on a person’s health – both are associated with an increasing risk of diabetes, cancer and heart and liver disease amongst others, and the risks get worse the more overweight people become. These illnesses put pressure on families, the NHS and society more broadly, with overall costs to society forecast to reach £50 billion per year by 2050 (Foresight 2007). The Foresight team described obesity as the ‘climate change of public health’. For all these reasons, helping the 26 million people who are currently overweight or obese to achieve and maintain a healthy weight should be central to any healthcare proposals and Weight Watchers is worried that the current proposals lack any emphasis on what should be the number one public health priority.

2. Responsibility for commissioning of weight management services for the public remains unclear

The Health and Social Care Bill seeks to dismantle Primary Care Trusts (PCTs), which have been the main commissioners of weight management services for overweight and obese patients. The vast majority of commissioning responsibilities will be transferred to new GP commissioning consortia. It is still not clear from the proposals within the Health and Social Care Bill and Public Health White Paper whether the new GP commissioning consortia will procure weight management services (e.g. NHS referral to group support programmes such as Weight Watchers) or whether the contracting process will be the responsibility of public health directors, who will sit within local authorities and lead on wellbeing services, or the NHS Commissioning Board, or be divided between them. This key question needs to be answered clearly and explicitly.

3. How will weight management services for the public be commissioned?

There is also a lack of clarity on how weight management services for individuals will be best commissioned. Specifically, more detail is needed on:

· Who will set criteria for ‘good results’ from weight management interventions

· How GP consortia will ensure that there will be equal, fair and transparent competition between NHS and non NHS providers of weight management services, all the time focused on outcomes

· How local ‘ need’ for weight management services will be quantified and thus strategies and funding aligned to meet those needs

· Who will take responsibility for making the type, range and volume of effective weight management services available which local populations deserve?

4. GP consortia will need training and support in commissioning weight management services

Over the last 6 years around two thirds of Primary Care Organisations (PCOs) have procured services from Weight Watchers. As a result the company has experience in NHS tendering and detailed its frustrations in evidence to the Health Select Committee’s recent inquiry into commissioning. It described an over-regulated, inflexible and insensitive process often driven by NHS commissioners with little apparent knowledge of the obesity literature and a seemingly poor understanding of the realities of weight management. Whilst GP involvement is likely to bring greater clinical expertise, most GPs are not trained in the skills and knowledge needed for effective commissioning of weight management services.

5. Danger that GPs will only commission services for the severely obese – when earlier intervention at lower BMIs more likely to be effective

To date over 65,000 patients from 102 PCOs have been referred to Weight Watchers, by around 1437 GP practices across the country. Most of these patients were severely obese (median weight approaching 15 stone and median BMI 35.1 kg/m² ) suggesting that primary care practitioners don’t tend to intervene until patients have complex health problems. However, most obesity care pathways recommend earlier intervention with behavioural change programmes (such as Weight Watchers) to help overweight people (at BMI 25 kg/m² upwards) to change their eating and physical activity habits before the situation becomes too acute. Because GPs are trained to ‘treat for weight loss’ rather than ‘prevent weight gain’, weight management services will continue to be offered only to the severely obese.

Lifestyle interventions such as Weight Watchers which seek to inculcate healthy eating and physical activity habits are effective in:

· Preventing healthy-weight people put on weight with age

· Preventing overweight people (I.e. BMI 25-30kg/m2) becoming obese

· Treating overweight people and obese people to achieve and maintain a healthy weight

Thus Weight Watchers offers interventions for both prevention and treatment.

6. No evidence that NHS reforms will solve the current inequalities in patient access to effective and evidence-based weight management services

Even though over two thirds of PCOs in England have bought Weight Watchers referral services for their patients, there is a huge variation in patient access to these services between PCOs. Over 75% of PCOs have purchased Weight Watchers in minute amounts (for less than 200 of their patients). This equates to referral to Weight Watchers being available to approximately 1 in 250 of the overweight/obese in sparsely populated PCOs. In more densely populated PCOs, around 1 in 3,300 overweight/obese patients would be offered Weight Watchers meetings paid for by the NHS. In reality Weight Watchers is only available to the select few who seek help through their GP practice. It is likely that this picture is indicative of patient access to other choices of weight management services.

7. Will the Health and Social Care Bill level the playing field between NHS and non NHS providers of weight management services to focus on outcomes?

Despite NICE guidance recommending that ‘healthcare agencies should recommend to patients, or consider endorsing, self-help, commercial and community weight management programmes if they follow best practice’, over the last 6 years Weight Watchers has fought for acceptance as an effective referral route for overweight and obese NHS patients. The previous Government’s obesity strategy, ‘Healthy Weight: Healthy Lives’, promoted commercial partnerships as an essential element to solve the "obesity epidemic". Yet this rhetoric seldom became a reality. For example, there was limited recognition of providers such as Weight Watchers within the Department of Health, or inclusion within local obesity care pathways drawn up by PCOs. Historically Weight Watchers has encountered commercial prejudices (i.e. not being perceived as offering as high a quality service as NHS providers) within NHS commissioning circles. It is hoped that proposals within the Health and Social Care Bill will promote a sea change in attitudes within the NHS to providers who have good quality data underpinning the effectiveness of the services they offer and who meet NICE best practice standards.

8. Weight Watchers welcomes judgement of services based on outcomes

Weight Watchers has invested heavily in research and evaluation. From this, the company knows what results it can achieve - particularly amongst the patients who are routinely referred by GP practices. These patients tend to be obese (average BMI 35 kg/m²) and have complex health problems. Over one third of all referrals lose 5% or more of their initial weight (Ahern et al, 2010) at 12 weeks and this results in a significant reduction in the risk of type 2 diabetes (Diabetes Prevention Programme Research Group 2002). Every kg lost results in a 16% reduction in risk of type 2 diabetes (Hamman et al 2006). Typically someone completing a 12 week course of Weight Watchers will lose around 5-6kg. Very few weight management interventions from NHS or non NHS providers possess similar evaluative data and many public health commissioners have contracted weight management services with unknown results. Weight Watchers welcomes the proposals within the Health and Social Care Bill which will encourage commissioners to buy services with proven outcomes.

9. Payment by results may affect equity of access to weight management services

Weight Watchers applauds the overall emphasis in the Health and Social Care Bill that it will be outcomes that matter, not targets or activity alone, with government pledging an end to the production line approach to delivering services. As such, providers will be paid according to their performance. However, this principle needs careful application to weight management services. Helping people lose weight is complex, often requiring behavioural intervention, backed up by regular and lifelong support and review. Losing weight requires great effort and patients often describe the weight loss journey as ‘an endless battle’ (DH 2010). Research suggests that high relapse and dropout rates are common in weight loss treatment studies – ranging from 10 – 80% (Inelman et al, 2005). For example, in the Counterweight study where weight management interventions were mediated by practice nurses (2004) retention was 22.5% at 12 months. There is a danger that if payment by results is insensitively applied to weight management service providers, then only patients with lower BMIs (25 – 30 kg/m²) and less complex health and socioeconomic needs will be accepted for referral and this will cause inequalities of patient access to weight management services. Payment by results in the weight management arena will discriminate against larger patients with complex health problems. The solution is to set realistic ‘performance indicators’ specific to different types of services (e.g. drug treatments, group support, one to one with a practice nurse, very low calorie diets) These very specific ‘performance indicators’ should be grounded in what the research indicates is achievable and should form the basis for any ‘payment by results’ scheme. It is unfortunate that discussions that Weight Watchers has had with commissioners across England so far regarding this issue have indicated that their desired results are certainly not based on the evidence of what is achievable for a specific intervention, but appear to be simply plucked out of the air.

These specific performance indicators could be shared with indicators for GPs. Weight Watchers submitted suggestions for QOF indicator topics in 2010, suggesting that in order to truly make weight management a priority in primary care, it is recommended that QOF indicators be developed to measure and incentivise the following:

% of patients over a BMI of 25kg/m 2 being offered weight management services

% of referred patients who complete with their chosen weight management solution

% of referred patients achieving a weight loss of at least 5% of their initial weight

10. Weight Watchers recommends an approved providers list of weight management services

A nationally maintained list of approved providers of effective weight management services to the public sector is vital to ensure people are offered safe and quality interventions. The weight management arena is diverse. Interventions and services are available from a wide range of agencies in the public and private sectors. These services vary in lots of different ways – but perhaps most pertinently in the level of data which has been collected on their effectiveness and their compliance with NICE best practice standards (NICE, 2006). In Weight Watchers’ experience the NHS commissioning process often lacked the specific expertise and interest in differentiating between effective and ineffective services. Whilst Weight Watchers welcomes the move towards integrating more clinical expertise into the commissioning of health services, an approved weight management service provider list would save everybody’s time and money in identifying services which meet NICE best practice standards, have proven effectiveness, are cost effective for the NHS and have the capability to deliver the scale of services needed across the country.

11. Weight Watchers is proven to deliver effective and cost-effective interventions

Over the last six years Weight Watchers has developed its health care services business. It:

· is a ‘willing provider’ of weight management services

· has a weight management programme which works – and (through independent research) knows what results it can achieve and meets NICE best practice guidelines for weight management interventions (NICE 2006)

· stands ready and has a tried and tested national operational infrastructure of over 6,500 weekly meetings which are embedded in local communities and run by local experts

· knows how to work with the public sector and has partnerships with over 100 PCOs across England

Over the last decade Weight Watchers has made significant investment in research to evaluate the efficacy of its methods, and the effectiveness of its Referral Scheme.

The economics are simple. A 12-session course of Weight Watchers (which on average achieves a BMI drop of 1.5 BMI units equivalent to 5-6kg) costs the NHS £55/patient. A single individual 12 minute consultation with a GP costs £36 and with a practice nurse £10 (Curtis, 2009). Weight Watchers has been proven to be a cost effective intervention for healthcare to help prevent and manage obesity, with a cost effectiveness ratio of £1,022 per QALY (Trueman and Flack 2006).

March 2011

List of References

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Brown, M and McPherson, K (2009) Computer modelling the health and economic

consequences of the Weight Watchers GP referral scheme, Obesity Facts, 2 (Suppl 2): 115.

The Counterweight Project Team (2004). A new evidence-based model for weight

management in primary care: the Counterweight Programme. J Hum Nutr Dietet, 17,

191–208.

Curtis, L (2009) Unit costs of health and social care 2009. Personal Social Services Research

Unit: The University of Kent. Available from www.pssru.ac.uk/pdf/uc/uc2009/uc2009.pdf

DH (2010) Maximising the appeal of weight management services. A report for the Department of Health and Central Office of Information. ESRO.

Diabetes Prevention Programme Research Group (2002) Reduction in the incidence of type 2 diabetes with lifestyle interventions or metformin. N Engl. J Med., 346, 393-403.

Foresight (2007) Tackling obesities: Future choices. Project Report, Government Office for Science.

Hamman, R et al (2006) Effect of weight loss with lifestyle intervention on risk of diabetes, Diabetes Care, 29, 2102 – 2107.

Heshka S, et al (2003) Weight loss with self-help compared with a structured commercial programme: a randomized trial, JAMA; 289, 1792-1798.

HoC Health Committee, Third Report, Session 2010-11, Commissioning, HC513-1-111.

Inelmen, E.M. et al (2005). Predictors of drop-out in overweight and obese outpatients.

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Jebb S A et al (2010) Referral to a commercial weight management programme enhances weight loss achieved in primary care. Obesity Reviews 2010, 11 (Suppl 1): S240.

Lloyd A and Khan R (2011) Commercial weight loss programmes; who benefits the most? Public Health Perspectives. In press

Lowe MR et al. Weight-Loss Maintenance One to Five Years Following Successful Completion of a Commercial Weight Loss Program. International Journal of Obesity 2001; 25: 325-331.

Lowe M. R, et al. Long term follow up assessment of successful dieters in a commercial weight loss programme, Int J Obesity 2004; 28, S29

Marmot, M (2010) Fair Society, Healthy Lives. Strategic review of health inequalities in England post 2010

National Institute of Health and Clinical Excellence (2006) Obesity: The prevention, identification, assessment and management of overweight and obesity in adults and children. NICE: London

Trueman, P and Flack, S. Economic evaluation of Weight Watchers in the prevention and management of obesity 2006: Poster presentation at the Conference of the National Institute of Health and Clinical Excellence