Saturday, December 22, 2012

Does Size Matter?

The silent killer

Globally Britain already has one of the highest levels of obesity.  By the end of the decade it is predicted that one in three adults will be classified as obese.  The health consequences of such a rise are staggering, as obesity is directly correlated with a myriad of diseases.  The obese population are nine times as likely to suffer from Type 2 Diabetes, three times as likely to develop hypertension and twice as likely to have a heart attack; the incidence of these conditions is set to rise by 146%, 61% and 43% respectively between 2006 and 2050.  Deaths attributable to excess weight have increased from 8.7% in 2003, to 11% in 2011.  That is equivalent to over 2000 more deaths annually now than 8 years ago.

The Weighty Cost

The NHS footed a bill of over £2 billion for treating obesity and related consequences in 2007; this figure is expected to double by 2015, and triple by 2035.  Significant though these figures are, the major financial cost of obesity lies in the indirect costs.  Each year, overweight and obese full-time workers are estimated to cost the UK £14.5 billion in lost productivity through absenteeism.  Obese workers, for instance, with three or more chronic conditions, account for over 10% of the full-time workforce and report an average of 60 unhealthy days and 18 missed work days per year.  This compares to 4 unhealthy days and 1.5 missed work days a year for workers with normal weight and no chronic conditions.  Obese people live, on average, nine years less than their non-obese counterparts, and the lost output was estimated in 2002 to be over £1 billion.   These indirect consequences and are expected to reach £23 billion in 2015.

Adding together the direct health costs (treating obesity and obesity-related diseases) to the indirect costs (lost output due to attributable sickness and premature mortality) the combined obesity bill is set to rise from £16 billion in 2007 to £50 billion by 2050 .  That is equivalent to over £400 of additional costs per person in the UK. 

Lightening the load

There is, therefore, a compelling argument to tackle obesity. Three modes of treatments currently exist:
·        Community-based interventions,
·        Pharmacological interventions,
·        Surgical interventions.

Community-based interventions cover population based regulation and fiscal measures, health education and promotion, as well as more individual based therapies in primary care.  These are tend to be the most cost-effective interventions.

Pharmacology interventions include prescriptions for the anti-obesity drug Orlistat. Orlistat works by preventing fat absorption, however, the drug does has side effects and it is often not a permanent solution, as weight is frequently regained after the medication is stopped.

Surgical interventions aim to limit the amount of food eaten and digested by altering the digestive system’s anatomy.  This is done via bariatric surgery.  Surgical procedures have risen sharply, with an annual growth rate of 24% over the past 10 years (though from a very low base).  Publicly-funded surgical treatment is restricted to those with BMIs over 40 (or 35, with comorbidities), making it available to only a small subset of the obese population.  Unfortunately, access to bariatric surgery is very inconsistent across Primary Care Trusts (PCTs), and this has led to a ‘postcode lottery’ as to who gets offered this as a treatment option.

What can be done?

Nationally, the enormous costs associated with obesity mean that treatments represent a key ‘spend to save’ opportunity for the coalition government.   Following the 2011 NHS reforms, commissioners’ will focus attention on payment by outcomes and their effectiveness in reducing chronic disease makes obesity treatments a prime candidate for funding – especially in the community.  Pharmacological and surgical treatments will continue to be used, but perhaps in conjunction with more a more integrated care pathway.  Currently community obesity services vary significantly across the UK; this is very different from a more standardised treatment approach for anorexia nervosa. 

Here we suggest a unique opportunity for local areas to develop and deliver a community obesity treatment service (COTS).  Tailoring a specialist obesity service around the individual brings together the three disciplines of diet, exercise and psychological therapies all under one umbrella.  Currently GPs tend to make three separate referrals, so COTS would be a way of making community provision for obesity more joined up.  It would also allow for the various levels of talking therapy to be offered; stepping up from basic advice and counselling to more specialist forms of talking therapy for eating disorders such as Cognitive Behaviour Therapy (CBT), Cognitive Analytical Therapy (CAT) and Acceptance Commitment Therapy (ACT).  The estimated cost of such a service would be £64 per patient per month.  Although there is a start-up and delivery cost, it should not be forgotten that all three main political parties have already nailed their colours to the talking therapy community mast.  Labour Party leader Ed Miliband has pledged to make access to talking treatments a legal right under any Labour NHS Constitution.  Liberal Democrat Deputy Prime Minister Nick Clegg has said “..much more can be done, more usefully using personal services including counselling and group therapy” and Conservative Prime Minister David Cameron has targeted his parties efforts and has offered Government money to increase talking therapy availability.  COTS could also take advantage of having many different funding streams, sourcing income from the public, private and third sector.

This is discussed further in Health Investor magazine December 2012 and was written by myself and Gerald Templer, an analyst at Candesic’s London office.

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