Weighing up the options

Are we standing on the threshold of a brave new world of streamlined health delivery where bureaucracy (aka management) disappears at the wave of a wand? Or are we teetering on a precipice facing a steep descent into a slough of despond, with a chaotic free-for-all of willing providers presenting GPs with a bewildering array of competing services?
   
However one may perceive the catharsis the National Health Service is about to undergo, it is clear already that GPs, who have enough to do struggling to deliver basic frontline medical services, will have to acquire new business skills and devote more time to exercising them. In a recent Pulse poll, less than half of GPs felt ready or confident enough to take on commissioning budgets, and two-thirds had no experience of significant commissioning. Only one in six admitted to having any experience of budget management. The majority felt it would be wrong to push ahead with the timetable for full GP responsibility by 2013.

THE COMPLEXITY OF OBESITY
What has this to do with the realm of obesity and its array of related chronic diseases? It wasn’t so long ago that the alarm was sounded over burgeoning present and future health service costs due to the increasing prevalence of overweight and obesity across all ages. Professor Sir David King, then government chief scientist, gathered a potent mix of scientific expertise behind the Foresight Report, explaining in detail the complexity of obesity, both as a medical condition, and in public health terms as a societal or structural challenge. To this were added gloomy prognostications of a NHS facing bankruptcy if the prevalence of obesity continues to rise. It comes with a daunting price tag approaching £50 billion by mid-century for the burden of obesity itself, with costly co-morbidities such as type 2 diabetes, cardiovascular disease and up to one in three cancer cases, not to mention dozens of less fatal, but still costly, complications such as sleep apnoea and osteo-arthritis.
  
If we are to avoid Foresight’s dire scenario, the whole ethos of primary care needs to be revised. It must incorporate medical prevention and management approaches as central strategies, recognising that the prevention of the chronic complications of obesity has long-term cost benefits. Therein lies a problem in the new world of GP commissioning.

MARKETING CAMPAIGNS
We cannot discard prevention and certainly cannot afford to relegate the most significant health challenge of the 21st century to a facile public health education approach such as Change4Life, reliant on the whims of industrial funding, in the full knowledge that such gimmicky marketing campaigns have failed to deliver so many times before. Repetitive hectoring about the responsibility of individual consumers to make healthy choices (i.e. refrain from buying) the very products that the food industry advertises and piles high on the supermarket shelves is not only disingenuous, but also counterproductive and to some extent stigmatising.
   
More importantly we now need the new government to demonstrate a much clearer grasp of the implications of the colourful Foresight ‘obesity system map’, which attempted to disentangle the mesh of factors influencing obesity. What it really demonstrated was that the financial burdens falling upon medical care from obesity- and diet-related illness are in reality what the economists like to call externalities – the invisible on-costs of the system that rewards with vast profits the businesses that deliver cheap and cheerful high-calorie food and beverage products. Unpalatable as it is, there is a parallel here with the tobacco and alcohol sectors that also inflict an enormous burden on our health system. Check out any cancer or CVD ward or look in an A&E department to see the body count after a weekend binge. It is the taxpayer who is still picking up the tab.
   
The reality facing politicians, planners and physicians is that unlike smoking where those concerned can stop overnight if they have the willpower, it is impossible for a large part of the population to wish away overweight and obesity. On present form we are on track to reverse past achievements in diminishing the impact of CVD, and may see an increase not only in type 2 diabetes, but in its more severe consequences including more limb amputations and blindness.
  
 By shifting the onus to GP commissioners to cope with (and plan for?) the rising tide of obesity-related disease, are we assuming that they will be willing to spend from their budgets now, to save someone else’s budget later? Governments and health managers have been markedly reluctant to display this level of altruistic behaviour, so this reliance on the GP’s lack of self interest involves an extraordinary leap of faith. Even if there are better incentives to deal with weight management and chronic disease prevention, there are simply too few GPs and too many patients needing to access limited services. A better solution is needed.

THE NEED FOR TRAINING
Certainly the outcomes framework must not shy away from the challenge of addressing obesity. That means that GPs, who should have some training and at least a modicum of knowledge on the issue themselves, need to be able to find suitably reliable and qualified providers to deal with the often complex nature of obesity management. The government’s White Paper puts great store in effectiveness of treatment and care provided to patients, the safety of treatment and care, and in assessing the broader experience patients have of treatment and care.
  
 There is therefore a need to ensure that patients in need of weight management do not find themselves left in the hands of people without proper training or competence. A kite mark of excellence in service delivery is the minimum a health consumer should be looking out for, and is something the National Obesity Forum is planning to provide.

WHAT TO DO?
What of the delivery side? In the inclement climate of health service upheaval and economic uncertainty, which health business can be confident in taking the strategic decisions requiring the long-term investment needed? Providers must ensure the capital infrastructure is in place to manage the inevitable further growth in obesity-linked hospital cases – which have already risen five-fold in a single decade.
   
In strategic planning terms, there is already a solid cohort of people who have spent their entire adult lives being obese. Given that we now have one in five adolescents completing their rite of passage into obese adulthood, with no expectation that this will change over the next decade, adult obesity is more likely to continue to rise than subside, and the consequent health problems will be multiplied. By middle age they are already more likely to put a heavy strain on health service provision than others; in particular the morbidly obese need in-patient treatment for longer. While everyone has been looking the other way, morbid obesity – defined by NICE as well as WHO as having a body mass index of 40 kg/m2 or above – has been rising. The Foresight Report – in an uncharacteristic oversight – sought to downplay morbid obesity, questioning whether the UK would ever emulate the USA in the “superobese” stakes, but it at least provided the caveat there may have been insufficient time to estimate the future growth. The obesity statistics already show that there has been a 50-100 per cent increase in morbid obesity among middle-aged women in recent years.
    
REALITY CHECK
A simple reality check should remind health service providers of the importance of taking a long hard look around the wards, rather than merely poring over statistics on their desks. Even the most punctilious 9-5 administrator would do well to look in on an understaffed ward at 2 am when a single nurse is confronted with a 200kg patient, who needs turning to avoid bed sores.
  
 The increasing burden is already well documented by the number crunchers. Finished admission episodes with a primary diagnosis of obesity last year totalled almost 8,000 – an eight-fold increase in a decade. The more telling figure for finished admission episodes with a primary or secondary diagnosis of obesity reflects the real scale of the burden; this rose over ten years from more than 21,000 to almost 103,000 cases. The 2009 total was 25 per cent higher than the previous year, with female admissions accounting for about 60 per cent of the cases. In terms of planning for bed capacity as well as human resources, the margin of flexibility (i.e. spare capacity) is probably far greater than competing providers could sustain.
   
When it comes to weighing the options over the White Paper, the future prospect of GP consortia commissioning services from competing providers will present new and significant challenges at a time when the obesity epidemic is likely to increase the strain on resources. Will obese patients in need of a range of medical services also benefit from the excellence that is expected, or will they find themselves again victims of oversight rather than foresight when it comes to their health?