Thursday 18 December 2003

PROFESSOR IAIN BROOM, MS LOUISE MANN, MS AMANDA AVERY, MS SALLY HAYES AND MS EMMA CROFT

  Q1080 Chairman: Professor Broom, you are on the outside. Have you any thoughts on this?

  Professor Broom: I think it is extremely important that we look at obesity as a whole issue, and that we go right across the whole spectrum in terms of the types of intervention that we need; and that includes physical activity and dietetics, and all aspects of lifestyle. It does perhaps also include drug treatment, but that is much further down the line. We have a huge problem in terms of the numbers of patients we have, but we do not have the resources in place to deal with it. We do not even have a clear clinical plan as to how to deal with it. That is one of the problems with the PCTs. They know there is a problem but do not know how to deal with it.

  Q1081 Jim Dowd: How much do you think this is led by a belief amongst PCTs, subconsciously and unspoken, that obesity is largely self-inflicted, in a way that many of their other responsibilities are not?

  Professor Broom: I think that is generally true—"it is your own fault; go away and do not eat so much and you will not be so fat". That is not the problem. One of the things I do with patients when I see them, is to try and shift the burden of responsibility, which has always been placed on them, and try and share that burden of responsibility. Immediately you almost see them relax, and once you get the patient relaxed and confident, and if they are in a position that they are motivated to change, that is the time when you can effect weight reduction.

  Q1082 Mr Bradley: You have been running obesity management schemes in general practice. We have already heard about the sheer numbers you would like to be involved in that. How do you get clinicians in your private practices to fit the management schemes into their programme? How do you gather the resources across the piece to make them effective, and how would you facilitate rolling out such a programme more widely? What are the implications of that from the experience you have had so far?

  Professor Broom: The Counterweight Programme was realised quite a few years ago by a number of specialist secondary care clinicians with an interest in obesity; but they also realised that the place you treat it is in primary care. We cannot cope with the numbers of patients, so we set about setting up a programme where we could roll out across primary care, in specific practices that showed an interest in dealing with obesity, and primarily aimed at providing tools both for patients and for the staff involved in these practices. That took about 18 months in the development of these tools, and then it was rolled out along an intervention programme, having audited 40 different practices for obesity and obesity co-morbidities or diseases associated with obesity. We looked at almost 200,000 case records, and out of that allocated specific co-morbidities and looked at the number of obese patients with these specific co-morbidities. Almost right across the whole range of disease, obese patients have major problems. We then set about a training programme within the practices, mainly aimed at practice nurses, but also with at least one of the GPs involved in the training programme. We did not stop at training. We then implemented the programme and gave support to the practices, with our weight management managers, who were all fully qualified dieticians, specially trained in obesity management. We rolled out that programme, and we are now into 18 months of the roll-out and have the first year's figures. In some respects we can answer the group versus individual treatment in two aspects. One in the Counterweight Programme is that outcomes for individual treatment are better than for groups. Secondly, the NHS tasked me to look at obesity treatment across the world, and looking at what treatments were effective. Group treatment is effective for one year, but thereafter individual treatment is much more effective than group treatment. If you are looking at the long-term management of obesity, then individual treatment is better; but you may in the first year get good results from group therapy.

  Ms Mann: As nurses, we do not get any training at all in weight management in our training. In primary care and with our practice, we did weight management, but very much in an ad hoc way, with no instruction at all. The Counterweight has provided us with a structured programme to help people, and it has been very much on a one-to-one basis. There is no group work at all in our practice. This really could not have been undertaken without the training that we had, and also the support, which has been incredibly important. As I understand it, our figures are very good when compared to national figures, a year down the line. The GPs endorse this support and the projects, but obviously realise that money is needed to be able to fund it, such as smoking cessation.

  Ms Hayes: Within Lees we could look at what has happened within primary care already. There is a lot of unstructured care for overweight and obese patients being undertaken by practice nurses. It is structured not based on the evidence, and generally fairly ineffective. Even when there was anti-obesity medication involved, the kind of weight loss was not effective. So we looked at it from a capacity point view and also a capability point of view, in terms of trying to shift this ineffective use of practice nursing resource, into a much more effective structured and evidence-based approach. We basically set up what we have termed "10 per cent clubs", which means that they are trying to lose 10% of body weight, into a 12-week group package. On the whole, it has been very successful. But we are very aware in Leeds that this is not the answer to obesity problems, and this is just one part of what we eventually will have, hopefully as a menu-based approach. That might be group work or it might be individual work. It might be referring patients off to commercial groups, on to leisure and all the different primary care providers and also into the acute trust if surgical intervention is necessary.

  Q1083 Mr Bradley: Are all those agencies signed up to participate?

  Ms Hayes: Yes. We tried to take a very inclusive approach from the start, and we had a health promotion input throghout. We have leisure services on our working group, and we have done a lot of work scoping what is available in the community already, so for each of our groups we know what is available in terms of community groups and leisure facilities; so people can basically be counselled on what is available for them so they can be referred to what is appropriate to their individual needs. We realise that it is very much a compromise between treating people very individually, but having the resources to do that and trying to take a more group approach.

  Q1084 Chairman: You said in your written evidence, Ms Hayes, that you had received funding for a 15-month project. Where did the funding come from?

  Ms Hayes: The funding came through a complicated route, through a neighbourhood renewal funding. That is one of these pots of money that people get offered now and again, and it is a mad scramble to try and bid in for that. It is not a good way to do things. Emma's secondment to the PCT finishes on 31 March. We have plans to take this project forward to roll it out to GP practices in our PCT, and to widen the scope of the practice into more physical activity, looking at morbid obesity and scrutinising the use of anti-obesity medication. But unless we secure funding from 31 March forward, then all our plans will be scuppered. One of the pleas from the heart is that that one-off funding just does not work. It is very de-motivating and when future plans cannot be made until funding is continued.

  Q1085 Chairman: What are the prospects of getting another source of funding to enable this to continue?

  Ms Hayes: We have gone back to neighbourhood renewal again. There are lots of changes in the rules and ways of getting such funding, but I am very hopeful that we are going to secure funding.

  Q1086 Dr Naysmith: It is very difficult to assess whether programmes are effective. What do you compare the people who go through these programmes with, in order to establish effectiveness?

  Professor Broom: We are basically looking at getting at least a 5% weight reduction in the population, and preferably towards 10%. In the published literature that is extremely difficult to achieve and maintain. The Counterweight Programme has certainly shown that nearly 50% of the patients who complete the programme achieve that; and this is by far the best figures of any study to date. It may not sound great, but if you have got nearly 50% of patients achieving 5% weight reduction in one year and maintaining that, that has a huge impact on other health issues such as blood pressure and tendency to type 2 diabetes.

  Q1087 Dr Naysmith: I am trying to get at how effective it is to spend resources on doing this. In the previous session Dr Campbell said that if you cannot do something for people who are overweight, then—

  Professor Broom: There were no additional resources put in, as far as general practice is concerned, by the individuals in primary care. What we did was to put in effectively a trainer. We trained the staff and then gave the staff support. So for 40 practices we have seven weight management advisors. We could probably easily double or treble that for each weight management advisor if this was not a research programme. If this was a programme that was run out, then one weight management advisor could easily look after 20 practices.

  Ms Avery: I wanted to respond to the former question. One of the outcomes would appear to be the issue about sustainability. Having worked in a number of community development programmes over the years, I do think that sustainability is a really important issue with respect to any scheme we undertaken when working with overweight people. Certainly, people who are obese are often quite vulnerable; they have a low self-esteem. If you offer them something and then withdraw it, that will not help their situation. Obviously, one of the great assets of working together with a commercial swimming sector was their particularly robust infrastructure. They are not organisations that are going to be pulled from under our feet, so that is a great strength of any such project. Going on from the last question, in the feasibility study we looked at other aspects of well-being apart from weight loss. Obviously, mental well-being is an important issue, and 12 weeks on, after linking in with commercial slimming organisations, there was a great improvement in self-esteem, et cetera, besides the 5% weight loss achieved; so different things can be looked at.

  Ms Croft: With the 10 per cent club, we are aiming for people to lose 10% of body weight, obviously, but the evaluation looks into changes in people's diets over the time, so whether they are eating more fruit and vegetables or whether they are being more physically active, because obviously all these have health benefits as well aside from the weight loss.

  Q1088 Mr Jones: You were speaking, Ms Avery, about links with the commercial sector. I think we are going to hear from some of the slimming organisations in the next session, but have you looked at the best use of resources, rather than set up your own organisations to help people slim, perhaps contracting in to existing organisations?

  Ms Avery: With any good obesity strategy, there should be a number of options for patients, so ideally a patient care pathway should include all these options so that patients can choose to go to different places that may meet their individual needs.

  Q1089 Mr Jones: The question I was asking you was whether, as primary care trusts, you have looked at managing the resources we dedicate to primary care, which is the most cost-effective route of getting people to weight.

  Ms Avery: The cost-effectiveness was the key issue when we set up the feasibility study addressing the lack of resources available. Obviously, we were quite keen to ensure that what was being offered met our requirements; that a quality product was being offered to patients referred from primary care in terms of dietary advice, behavioural support, advice on physical activity; so we were keen to ensure that the product being offered was appropriate to patient needs in primary care.

  Q1090 Mr Jones: Would you look at whether they lost weight or not?

  Ms Avery: Yes.

  Q1091 Mr Jones: You mentioned a long list but did not mention the one thing that you are asking to do in the first place.

  Ms Avery: In terms of costs, we know it is much cheaper to refer to a commercial slimming organisation than to prescribing either Orlistat or Sibutramine; so you are looking at £55 per patient for 12 weeks, compared to £126 for Orlistat for the same length of time. That does not include the additional support cost that should be given to patients prescribed Orlistat—and Sibutramine is even more expensive. In terms of comparison with drug costs it is much cheaper.

  Q1092 Mr Jones: What about staffing costs?

  Ms Avery: The staffing costs were minimal in that, obviously, primary care were required to do just a little bit of admin, but other than that there were no additional costs.

  Q1093 Mr Jones: Can we have some information on these costs?

  Ms Avery: Yes.

  Q1094 Chairman: You could write in with the information.

  Ms Avery: Yes. Certainly one of the public health analyses has looked at the costs of 10% weight loss per patient, going to a commercial slimming organisation; and he was astounded by the cheapness, but I do not know the exact figure.

  Q1095 Dr Naysmith: We have spent quite a lot of time this morning talking about diet and drugs, and various other ways of managing overweight and obesity; but physical activity obviously has a part to play in it. Would you like to comment on whether you feel there is room for specialists in primary care whose job it is to encourage patients to be more active? You can comment at the same time on what part you think physical activity promotion should play in that kind of programme?

  Professor Broom: Physical activity has to be part of any rational programme of clinical care. Who gives that advice is open to question because especially in the very obese patients physical activity can be extremely difficult, and in some cases certain types of physical activity could be damaging. Work is required to look at what type of physical activity is best for individual patients. Some patients may require different types of activity. They are very simple things, like switching off the television when you are eating, because patients start to talk and make small hand movements; and it is amazing how much that can add up in terms of energy expenditure. If you leave the television on and sit in front of it, there is no conversation, and you basically eat away and there is no energy expenditure.

  Q1096 Dr Naysmith: That is an interesting reply. What I am really getting at is whether there is room for people who specialise in this activity—nurses perhaps taking courses?

  Professor Broom: I think we should link in and have appropriate training. The Counterweight Programme does provide training in physical activity through the nursing staff, and they get at least advice in terms of what activity is appropriate.

  Q1097 Dr Naysmith: I know that in Bristol GPs can prescribe going to the sports centre for sessions there. Is there room to expand this much more?

  Professor Broom: Very much so.

  Ms Croft: It is very important that we have strong links with organisations like leisure services, and use their expertise and building on this. As part of this project, we are helping to train people who are already exercise specialists in being able to deliver appropriate sessions or activities to people with obesity, which are supportive in a safe environment, and making sure that primary care are aware of what physical activity opportunities are available around their surgery. Another possibility is an advisor within primary care who could counsel people and find out if they are prepared to take on more activity and at what level; and maybe even take them along as an introduction session. That is something that has been piloted which worked quite well, because it can be quite intimidating going along to the gym, etc for the first time, and maybe a bit of hand-holding is required.

  Q1098 Dr Naysmith: It is emerging clearly this morning that there are lots of different things that feed in to managing obesity, and that often means working with different groups in the community, for example people in the education sector, transport planners, leisure services and various other council departments, and of course the National Health Service. How do we get all these people to work together? Do you have any experience in Leeds of trying to get people to work together in a focused way?

  Ms Hayes: We have a very positive experience of working with leisure services in Leeds, and they are very engaged in our project. The sustainability of it is the crux for us; and local authorities and leisure services need to be encouraged to recognise their role in health and in health promotion because people who are overweight do not fit into going to a council swimming pool or whatever, so we need to see what leisure services can be offered to encourage people to access the leisure opportunities in settings appropriate to their needs.

  Q1099 Dr Naysmith: In your experience at the primary care trust level, do they want to try and do that?

  Ms Hayes: Yes, and it has generally been individuals within leisure services who are willing to be involved. They go back to their organisations, and again they are one voice among a lot of priorities. It is how we can get that through at a higher level in the organisations.