HC 1048-III Health CommitteeWritten evidence from Weight Watchers UK Ltd (PH 33)

Summary

Government’s public health proposals have strengths – but implications need to be thought through.

Weight Watchers has public health expertise and experience to comment on government proposals.

Obesity ignored within government proposals.

Weight management services for adults an essential part of obesity solution – to “nudge” alone is not enough.

Confusion over commissioning weight management services.

Strategic gap between public health and GP consortia in planning weight management services.

Funding flows complicated and boundaries unclear.

Public Health England or NHS Commissioning Board should commission or control commissioning of lifestyle modification based weight management services.

Lack of expertise in commissioning weight management services exacerbated.

Weight Watchers recommends a “qualified providers” list of weight management services to the public sector.

1. Government’s public health proposals have strengths – but implications need to be thought through

Weight Watchers welcomes many aspects of the government’s public health proposals. They have many strengths, particularly local authority involvement, which promises to bring health back into the centre of communities and de-medicalise the notion of wellbeing. They represent an opportunity to re-fashion the commissioning processes for public health services which are woefully inadequate in relation to obesity. Generally, there are not enough service options available for those who are overweight or obese, and the commissioning of these services is often not an evidence-based process. Weight Watchers appreciates the focus on outcomes, especially when applied to weight management services for NHS patients. Providers of these services should know and be able to demonstrate the weight loss outcomes their interventions can achieve.

However, the proposals within the public health white paper represent massive change, especially in how public health will be organised. Weight Watchers has concerns over the proposed speed of change as many of the organisational implications, particularly related to access to services to help people control their weight , do not appear to have been thought through.

2. Weight Watchers has public health expertise and experience to comment on government proposals

Weight Watchers has submitted previous evidence to your Committee demonstrating its expertise, experience and effectiveness as a provider of lifestyle modification based weight management services to the NHS. It runs 6,500 weekly meetings in the UK facilitated by 1,700 leaders trained in simple behavioural change techniques with an evidence based holistic approach to weight management (healthy eating, physical activity, changing behaviours all in supportive environment). To date, 65,000 patients have been referred to a 12 session course of Weight Watchers meetings by 1437 GP practices across the country with favourable results (Ahern et al 2011). There is additional good quality evidence demonstrating the efficacy of Weight Watchers methodology (Heshka et al 2003, Jebb et al 2010) and the programme meets NICE best practice standards (NICE 2006).

Two thirds of Primary Care Organisations (PCOs) have worked in partnership with Weight Watchers to make Weight Watchers meetings available free of charge to their patients. Some PCOs have targeted lower socioeconomic localities, and there is some evidence to suggest that the rates of completion and weight loss in low income groups are comparable to those from higher income groups (Lloyd and Khan 2011). Indeed in an evaluation of their scheme within North Somerset NHS trust, 40% of referrals to Weight Watchers were from the most deprived quintile, yet attendance and rates of weight loss were similar to those found within a national audit (Dixon et al 2011, Ahern et al 2011). The authors concluded that NHS referral to personalised weight management services, such as Weight Watchers, was a successful way of reaching the most deprived populations. The inverse socioeconomic gradient of obesity prevalence is a clear indication that deprived communities need access to weight management services – yet the government’s proposals contain no detail on how this will be achieved. In Weight Watchers’ view the Government’s response to the Marmot review on health inequalities could be far more assertive.

3. Obesity ignored within government proposals

Weight Watchers has consistently argued that obesity should be the number one public health priority. 61% of adults are overweight or obese (HSE, 2009) and this has serious implications for individuals’ health and well being. Your Committee’s own estimates in 2004 of direct health care costs for the treatment of obesity and its consequences totalled £991m-£1,124m, equating to 2.3%-2.6% of NHS expenditure (House of Commons Health Select Committee, 2004). These estimates were based on 2002 data, and the Government Office for Science Foresight report projected a seven-fold increase in direct health costs of overweight and obesity by 2050 (Foresight, 2007).

Despite obesity’s pivotal role in public health, it is largely ignored within the public health white paper and its detailed daughter consultation on funding and commissioning routes. Weight Watchers acknowledges the intention of DoH to issue a specific framework on obesity (and has been part of a team of experts asked to consult on its development); but this signals a “bolt on” plan rather than a recognised “cross government” priority within the legislative process to reorganise public health in this country.

4. Weight management services for adults an essential part of obesity solution – to “nudge” alone is not enough

Through Weight Watchers’ 50 years’ experience of supporting people to manage their weight, it understands that obesity is a complex and multi-factored disease. It endorses Foresight’s conclusions that tackling obesity requires an equally complex response, encompassing environmental and regulatory measures alongside lifestyle modification interventions, which seek to change an individual’s behaviours associated with their diet and physical activity. All Weight Watchers’ experience and research indicates that to “nudge” alone, is not enough to change health behaviours in the long term. In order to help those who are already overweight or obese requires intensive treatment and follow up. For many people the journey to control their weight requires significant effort sustained over a lifetime. They need regular support from others (peers and people trained in behavioural change techniques) plus an environment which encourages healthy lifestyle habits. Weight Watchers is encouraged that the Nuffield ladder of interventions is the government’s strategic blueprint for public health, because this reinforces the important point that behavioural change interventions (such as Weight Watchers) are a crucial part of the solution. Actions are also required from other players including the food industry, catering sector, local planning, schools, nurseries, the leisure industry, government and the NHS, consumer organisations, transport agencies, and higher and further education providers.

5. Confusion over commissioning weight management services

The public health white paper focuses on prevention and protection. It makes limited mention of the health service domain of public health practice. Whilst the detailed consultation on funding and commissioning fills in some of these gaps (ie it is now clear that weight loss surgery and drug treatment will be the responsibility of the NHS), there are still significant uncertainties as to how lifestyle modification based weight management services, which are needed by an estimated 26 million adults in England, will be commissioned. Whilst these services have traditionally been seen in a “obesity treatment” context, they also have a preventive function in:

Preventing overweight adults becoming obese and moving up the BMI continuum, thus limiting progression towards more costly and invasive treatment such as anti-obesity medications or bariatric surgery

Reaching “at risk” children by helping overweight/obese parents inculcate healthy lifestyle habits within the home.

For these reasons, it is vital that there is absolute clarity over who will commission these services, for both overweight and obese adults, particularly for individuals on low incomes and in deprived communities.

6. Strategic gap between public health and gp consortia in planning weight management services

Weight Watchers agrees that changing, redesigning and re-configuring publicly funded weight management services is badly needed. Currently huge amounts of taxpayers’ money are wasted by using expensive health professionals to deliver simple behavioural change interventions that can be more cost effectively provided by behavioural change agents (such as Weight Watchers). Results from a randomised controlled trial indicated that weight loss outcomes at one year were significantly greater in overweight and obese patients referred to Weight Watchers compared to those who received standard care delivered by GP practices (Jebb et al 2010). These results were recently corroborated by an independent study which assessed the effectiveness of a range of weight management programmes provided by the NHS and other service providers. The patient group referred for a 12 session course of Weight Watchers achieved a medically significant weight loss at programme end and sustained this medically significant weight loss at the one year follow up. Out of all the interventions evaluated in the trial only Weight Watchers patients achieved significantly greater sustained weight loss at the 1 year follow up, compared with those who “went at it alone”, simply being offered 12 weeks of vouchers to attend a local leisure facility (Lewis et al 2011).

Given the lack of clarity within the Government’s proposals on who is responsible for commissioning services to help people change their habits to reach and maintain a healthy weight, there will be a strategic gap in service planning between GP consortia and public health. Additionally few GPs have the management strength or appetite to effectively plan service provision for populations across localities – especially services which impact on public health. It is hard to see how the public health proposals and NHS reforms will promote joined up planning, commissioning and provision of weight management services in a way which will meet the wants and needs of local communities.

7. Funding flows complicated and boundaries unclear

Having studied the detailed consultation on funding and commissioning routes for public health, Weight Watchers found the proposed funding arrangements over-complicated and the boundaries unclear. There is a lack of clarity of what services are covered by different budget segments linked to public health. Specifically there is a danger that a ring-fenced budget for public health will be expected to cover all public health interventions; when many will continue to be the responsibility of other organisations. For example, GPs may perceive that “tier one” lifestyle modification weight management interventions should be funded by ring-fenced public health budgets held by local authorities; whereas public health directors may perceive that these services should be covered by NHS budgets. Without clear and directive guidance on where weight management sits and what patient groups sit where; there is a real risk that obesity treatment (for those with a BMI>30kg/m2) is seen as the responsibility of GPs, whilst those patients who are overweight are lost in the middle with no clear services or support strategy. The uses to which the ring-fenced budget is to be put must be identified and the size of this budget estimated from a realistic baseline that reflects local needs.

8. Public Health England or NHS Commissioning Board should commission or control commissioning of lifestyle modification based weight loss services

The government’s proposals for public health and NHS reforms suggest that GP consortia will commission lifestyle modification based weight management services for their patients. This will result in a conflict of interest. GPs have a vested interest in providing these services themselves, when in reality there is evidence that other providers are equally or more effective (Ahern et al 2011; Jebb et al 2010; Lewis et al 2011) and cost the tax payers less (Curtis et al 2009). The Health and Social Care Bill proposed that GPs will have more autonomy over the services they commission for their patients and it seems that public health directors, who have the strategic insights in planning services for populations, will merely act in an advisory role. In this scenario it only seems fair and transparent that either Public Health England or the NHS Commissioning Board should control the commissioning of these types of public health services for patients.

9. Lack of expertise in commissioning weight management services exacerbated

Current proposals within the public health white paper are likely to exacerbate the current lack of expertise in commissioning lifestyle modification based weight management services. In Weight Watchers’ experience of tendering to provide services for NHS patients, many commissioners lack knowledge of the weight management research literature and achievable outcomes and this is exacerbated by poor understanding of the realities of trying to manage weight. In the future GPs will be at the centre of the commissioning process. However, too few are weight management specialists. Indeed the Quality and Outcomes Framework has not encouraged the development of weight management skills and knowledge amongst GPs, whilst there is more expertise within public health directorates; this is likely to become disengaged from the commissioning process under current proposals.

10. Weight Watchers recommends a “qualified providers” list of weight management services to the public sector

Having now studied the detail within the consultation on commissioning and funding routes for public health, Weight Watchers will continue to argue for a nationally maintained list of qualified providers of effective weight management services to the public sector. In the chaos and confusion which will follow the implementation of new public health legislation it is vital that people are offered safe and high 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. However many commissioners lack the specific expertise and interest in differentiating between effective and ineffective services, often relying solely on NICE best practice standards as a tick box exercise rather than taking outcomes, cost effectiveness, equality of access and scalability into account.

A list of qualified providers would save significant time and money so that commissioners can focus on getting the best services to the most deserving people faster. Inclusion within this list would depend on:

Outcomes of service/intervention – ability to demonstrate efficacy.

Savings – versus alternative services or doing nothing.

Cost effectiveness to the NHS.

Safety, including compliance with NICE guidelines.

Referral criteria, ensuring equality of access.

June 2011

List of References

Ahern A et al (2011) Weight Watchers on prescription: An observational study of weight change among adults referred to Weight Watchers by the NHS, BMC Public Health, 11, 434.

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

Dixon K et al (2011) Evaluation of weight loss outcomes for obese adults referred to a choice of three commercial weight management providers. Poster Presentation given at South West Public Health Scientific Conference, Weston-super-Mare, February 2011.

Government Office for Science (2007) Foresight Report “Tackling Obesity: Future Choices – Modelling Future Trends in Obesity and their Impact on Health” 2nd Edition.

Health Survey for England (2009) www.ic.nhs.uk

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

House of Commons Health Select Committee (2004) Obesity: Third Report of Session 2003–04. London: The Stationery Office.

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.

Lewis AL et al (2011) A randomised controlled trial to compare a range of commercial or primary care led weight reduction programmes with a minimal intervention control for weight loss in obesity; the lighten up trial. Obesity reviews; vol 12 (suppl 1):61.

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

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.

Prepared 28th November 2011