HC 1048-III Health CommitteeWritten evidence from Cambridge Weight Plan (PH 113)

Summary

Cambridge Weight Plan (CWP) offer a number of flexible weight management programmes, which provide the overweight and obese with an effective and sustainable way to achieve a healthy weight. Whilst CWP welcome many of the Government’s plans, we have a number of comments to make:

Most experts agree that central government, local government and the NHS will all have to work in co-operation to achieve real improvements in public health. The Government recognise this and many of their plans work on the basis that all will co-operate without any friction, but this is by no means guaranteed. It is essential that systems are found to ensure that local government can work successfully with the NHS and that their services complement each other.

CWP have some concerns over the amount of money allocated to tackling obesity. Considering the vast sums that obesity will end up costing the NHS, we would like more clarity on how the Government’s £4 billion a year for public health will be allocated and reassurances that obesity treatment will be properly funded. This is important given the huge savings that could follow from overweight and obese people successfully managing their weight.

CWP also question whether the Public Health Outcomes Framework, as per its format in the recent consultation, will successfully achieve its objectives of encouraging better public health in local areas through measuring particular indices. Experience with the QOF has shown that merely measuring the number of obese people in a given area has almost no impact; instead, an Outcomes Framework needs to measure amongst other the number of people treated for obesity, to encourage innovation and the sharing of best practice.

Introduction

1. Obesity is a major and growing problem public health problem in the UK. According to data released by the Health and Social Care Information Centre in February 2011, over two thirds of men and half of women in England are overweight or obese. The 2007 Foresight Report on obesity predicted that by 2050 obesity could affect 60% of adult men, 50% of adult women and 25% of children. The resulting costs to the NHS could be in the region of £10 billion a year, with wider costs to society reaching nearly £50 billion a year. This is due to the large number of serious health conditions associated with obesity such as heart disease, type 2 diabetes, stroke and increased risk of cancer.

2. CWP offer a variety of weight management options, including Low Calorie Diet (LCD) and Very Low Calorie Diet (VLCD) programmes, for those who are overweight and clinically obese. They are primarily aimed at those with severe weight problems, typically with a Body Mass Index (BMI) greater than 30.

3. We offer flexible programme options between 415 and 1,500 kcal/day, all using a nutritionally balanced formula food as their foundation. The products contain carefully formulated amounts of energy, protein, carbohydrate, fat, fibre and all essential micro-nutrients, and at least 100% of the RDA of essential vitamins and minerals when used as a VLCD.

4. In addition to the weight loss modules, CWP also provide weight stabilisation and long-term weight maintenance programmes. These are achieved through a gradual re-introduction of different types of food and continuous professional support.

How Cambridge Weight Plan Programmes Work

5. CWP products and programmes are only available through specially trained and accredited Cambridge Consultants, who provide initial screening and advice to clients. The Consultants provide extensive individual and/or group out of hours support, which is a major factor in maintaining motivation and achieving long-term maintenance of weight loss.

6. Protocols are in place to ensure that clients only participate in appropriate programmes, to ensure that they do not have any listed contraindications, and to refer the client to their GP if necessary. All clients are also strongly encouraged to see their GP before commencing a programme.

7. The CWP programmes use a four-stage process: preparation, losing weight, stabilising weight, and weight maintenance.

8. During the weight loss stage, clients with one stone or more weight to lose can use a very low-calorie diet programme, completely avoiding conventional foods for an appropriate period of time. These are replaced with three or four specially formulated, nutritionally balanced soups, shakes, porridges or meal bars a day. This approach allows participants to take a complete break from traditional food, with which they have a difficult relationship.

9. A slightly higher energy very low-calorie diet (615 kcal/day) allows one conventional meal a day. In accordance with the NICE Obesity Guidance, very low-calorie diets can be used for up to 12 weeks at a time.

10. There is a further range of Low Calorie Diet programmes, in the range of 810–1200 kcal/day, for people needing to lose less weight or choosing to lose weight more gradually. These programmes use a mixture of CWP products and conventional meals. They are organised into different steps with the number of calories increasing at each step.

11. Following the weight loss stage, weight stabilisation and maintenance is guaranteed through a two-step approach. Different types of food are re-introduced gradually, so that clients do not regain the weight they lost. Once weight has stabilised, continuous professional support is provided to help clients to develop the necessary skills to maintain their weight in the long term. This continued support and use of meal replacements are two of the key elements of successful weight maintenance, as has recently been shown in a one year maintenance trial using Cambridge Weight Plan in Sweden published in the British Medical Journal in June 2011 (Johansson K etal BMJ 2011; 342:d3017

12. Additionally, clients can follow Cambridge Active, a stepped programme of physical activity which encourages them to develop appropriate activity and increase fitness levels. This can range from easy to do stretches to full aerobic movements and pool exercises.

13. CWP would like to thank the Health Select Committee for this opportunity to comment on the Government’s public health plans.

The creation of Public Health England within the DH

14. CWP welcome the establishment of Public Health England as a body that has the potential to provide national level advice on options available to health professionals to tackle public health problems and encourage the use of innovative solutions to these problems.

15. Particularly in the field of obesity, CWP believe that Public Health England should not be restricted to merely providing dietary advice. Public Health England should have a broad remit in ensuring that up to date advice on tackling obesity, including advice on private providers, is available to all commissioners. Public Health England should also be able to actively recommend all methods of tackling public health problems, especially when there is a good evidence base to show clinical effectiveness, are considered and used. CWP has sometimes found that cultural barriers amongst health professionals can prevent patients from accessing the best options available to them; indeed CWP have numerous examples in which doctors point blank refuse to cooperate despite the scientific evidence that many people safely and effectively lose weight with CWP programmes. Encouraging professionals to overcome such barriers should therefore be part of the role of Public Health England.

16. In addition, Public Health England is in the best position to ensure that any guidance provided is consistent across the country. This will help to counter some of the inconsistent advice that is provided in the area of obesity, allowing for a more uniform and effective approach in tackling obesity levels across the country.

The public health role of the Secretary of State

17. CWP welcome both the priority accorded to public health and the formation of a Cabinet Sub-Committee on Public Health, as only through working across Government can public health problems effectively be tackled.

18. We are keen to ensure that obesity will be prominent on the public health agenda considering the ever increasing costs that the growing obesity rate will place on the NHS and ultimately the Exchequer. Providing effective solutions in a uniform manner across the country has the potential to significantly reduce the future cost on the NHS of obesity related co-morbidities. In this respect, programmes such as those offered by CWP, which not only help individuals to maintain their weight loss but also encourage personal responsibility, could prove to be a cost-effective alternative to other existing treatments for obesity.

The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

19. CWP strongly welcome the focus on local authorities working to improve outcomes in their area as it is clear that national level guidance on obesity needs to be complemented by appropriate and relevant involvement of local and national stakeholders. Devolving decisions on local priorities makes sense: numerous studies have linked deprivation to obesity, so poorer areas will require greater focus on obesity.

20. The role of local government in public health should also encourage innovative working and the sharing of best practice, particularly in the treatment of obesity since it is the responsibility for local authorities to commission weight management services.

21. One concern is that the Government’s entire strategy rests on close co-operation between local government and the NHS—this is absolutely essential for public health problems to be properly tackled, yet far from guaranteed.

22. Another concern is over the £4 billion ring-fenced public health budget; cash-strapped local authorities may be tempted to look at this ring-fenced budget and push for the broadest definition possible of what public health constitutes. In addition, to be effective, obesity budgets needs to be sufficient to allow for the different options to be effective. Not providing sufficient resources will ultimately reduce the future potential for NHS savings relating to the reduction of obesity linked diseases.

Arrangements for public health involvement in the commissioning of NHS services; arrangements for commissioning public health services

23. A key point to acknowledge here is that GPs need help to commission weight management services. Many GPs are not familiar with treatments available for the obese and consequently do not have the expertise to commission appropriate services (indeed, many GPs are embarrassed to broach the subject with overweight or obese patients in the first place). It is here that guidance from Public Health England and NICE becomes crucial.

24. In terms of obesity treatment, there is also some confusion over responsibility for who does what: Public Health England will provide dietary guidance, responsibility for commissioning surgery and drug treatment for obesity will remain with the NHS, whilst responsibility for weight management—the crucial treatment that fills a therapeutic gap between the above options—rests with local authorities. These confused lines of responsibility require clarification.

25. Nevertheless it is clear that the NHS must be involved in commissioning public health services as it clearly has a stake in their success—it will be the NHS that will remain responsible for treating patients if other public health services fail to prevent and reduce obesity (related to the point above in section 21). The weight management programmes that CWP offer can be provided at different levels of an obesity treatment pathway and the one factor that connects all these levels is the involvement of the NHS.

The structure and purpose of the Public Health Outcomes Framework

26. The Public Health Outcomes Framework is helpful but limited and, on the specific issue of obesity, the Framework is almost certain to fail in the key objective of creating a healthier Britain. The reason for this is that the Framework fails to reward areas that actively take steps to bring obesity rate i.e. through measuring the number of people who lose a percentage of weight over a set time.

27. Experience with the QOF has shown obesity experts that simply registering the number of obese people does almost nothing to help bring down the obesity rate. A better Outcomes Framework would also help local authorities learn from each other and share best practice.

28. Measuring the numbers of people who have lost weight would also target money to those in need: as previously noted, the more deprived the area, the more likely there will be greater numbers of obese people living there.

Arrangements for funding public health services (including the Health Premium)

29. Although CWP welcome the £4bn of ring-fenced money for public health that the Government has promised, we still have a number of concerns. As noted above, the definition of public health can, at times, be a broad one and it is uncertain how funds will be allocated. We are also concerned that treating obesity may not be a high enough priority for this Government and so not enough money will be spent on funding effective obesity treatments. Such treatments would also prove to be highly cost-effective considering the burden that an increasingly overweight UK population will place on the NHS.

30. On other aspects of public health funding, there is a clear case for incentivising Local Authorities to take action against obesity through the judicious use of extra money distributed via a health premium. Targeting this extra money to effective, and cost effective, weight-management services will ensure that the poorest in society are able to lose weight, live healthier lives and ultimately improve their life chances.

31. Programmes such as those offered by CWP, which help individuals to take responsibility for their weight, also help people beyond their weight management issues in taking greater responsibility in other aspects of their lives.

How the Government is responding to the Marmot Review on health inequalities

32. The Marmot Review concludes that “obesity is associated with economic and social deprivation...and is becoming increasingly common”. This makes the Government’s health premium idea extremely welcome, as is the Government’s commitment to maintain ring-fenced spending on public health. Notwithstanding our concerns over this spending, expressed above, in past times of austerity public health spending has to often been the first victim of cuts.

33. As we note, the Government could do more to tackle inequalities through slight adjustments to the Public Health Outcomes Framework. CWP also believe that greater use can be made of innovative ways of funding healthcare, which can reduce inequalities. Increased use of Personal Health Budgets, for example, would enable socially deprived individuals to take greater control over their care and exercise greater choice over who provides this care.

Conclusion

34. CWP broadly welcome the Government’s focus on public health and its commitment to ensure that public health services are properly funded. We do however see some problems ahead, in particular the lack of mechanisms to ensure that central and local governments work together, as the Government wishes them too. CWP also question whether the Government is ambitious enough in the outcomes that it has proposed in its Outcomes Framework.

35. There is a lack of clarity around some of the Government’s proposals for public health, and, until the publication of the Government’s obesity strategy, which we expect soon, CWP are unable to comment in more detail on the Government’s plans for tackling this key public health problem.

June 2011