Providing enhanced services in obesity management
Dr Peter Stott describes in detail what is involved in applying to provide enhanced services for obesity care
The new GMS2 contract offers practices the opportunity to deliver enhanced quality in terms of clinical, organisational, additional and patient experience. But individual practices will also be able to choose to deliver enhanced services in other quality areas that are relevant to their specific populations and to be paid for delivering those services.
Section 2.13 (II) of GMS2 describes this category of enhanced services as: 'Services which are not provided through essential or enhanced services which might include more specialised services undertaken by GPs or nurses with special interests and allied health professionals and other services at the primary-secondary care interface. They may also include services addressing specific local health needs or requirements, and innovative services that are being piloted and evaluated.'
Such services will need to be negotiated with the PCT much as PMS Plus services currently are for PMS GPs. Those that are likely to be taken up will be evidence-based strategies that have been shown to deliver benefits for patients. The management of obesity is such an area.
Obesity is important because it the major cause of type 2 diabetes and of many other conditions. In the US, it has been estimated1 that obesity is responsible for:
· 61 per cent of type 2 diabetes
· 17 per cent of all hypertension
· 17 per cent of coronary heart disease
· 30 per cent of gallbladder disease
· 24 per cent of osteoarthritis
· 11 per cent of breast cancer
· 34 per cent of uterine cancer
· 11 per cent of colon cancer.
For the UK, CHD is a particular problem. Some areas of the country have more problems than others. These include those with large Asian and Caribbean populations, elderly populations, lower socio-economic groups, Scotland and Northern Ireland.
If you think obesity is a particular problem in your area you should approach the PCT and suggest a structure for an enhanced obesity service. Your application should be modelled on the current quality initiative framework and include:
la needs analysis for your practice (basic epidemiology and morbidity)
lthe evidence base for the intervention you choose to adopt
lthe outcome measures that will demonstrate success
la business plan.
In the UK as a whole, half the population is currently overweight (BMI >25kg/m2) or obese (BMI >30kg/m2). You should compare your own practice with this statistic to show you have a particular problem.
It is unlikely you will be able to quote statistics for your whole practice, but there is no reason why you could not collect data on consecutive patients for a week, so as to get randomly obtained, statistically meaningful figures for patients attending the practice. In the longer-term you could start recording the height and weight of everyone you see.
You may also like to look at the BMIs of patients attending your diabetes and cardiovascular clinics. An enhanced service will need to involve some intervention that would not normally be classed as 'essential' under the GMS2 contract.
Group work, dietetic input, psychological support or exercise prescription would be examples of enhanced services that might qualify.
A key group of patients to include are those who have pre-diabetes; identified as having a raised impaired fasting glucose or impaired glucose tolerance on an oral glucose tolerance test. Providing oral glucose tolerance testing and screening for pre-diabetes in the practice would be another example of an enhanced service which would save on referral to the local laboratory.
Pre-diabetes should be suspected in patients at risk of diabetes, who:
lhave existing cardiovascular disease (including hypertension and dyslipidaemia)
lare obese (BMI >27kg/m2)
lhave family history of type 2 diabetes
lrace/ethnicity (particularly those from Africa/Caribbean, Asia, Pacific Islands)
lhave history of gestational diabetes or of babies over 9lb.
The evidence base for the benefits of weight loss is extensive. A 10 per cent loss of body weight in an obese person will result in:
lmore than 20 per cent decrease in premature deaths
lmore than 30 per cent decrease in diabetes-related deaths
lreduction in blood pressure by 10mmHg
· 10 per cent benefit in cholesterol levels.
Lifestyle intervention (exercise and weight loss) in those with pre-diabetes can also reduce the chances of becoming diabetic in the next three years by up to 50 per cent and in the next six years by up to 40 per cent3,4.
Drug therapy can add to success. In the Xendos study of obese patents5 (BMI >30kg/m2) after four years of treatment, use of orlistat decreased the development of type 2 diabetes by an additional 37.3 per cent compared with lifestyle change alone. In obese patients who already had impaired glucose tolerance at baseline, the reduction was an additional 45 per cent.
There are five strategies on the road to weight loss. They are:
lsurgery for patients with extreme BMIs (>40kg/m2) where other methods have failed.
Your enhanced service will need to include concepts that are not already available to patients through the category of essential services.
Outcome should not be measured simply in terms of weight loss, although this is obviously important. Weight maintenance is sometimes more realistic, particularly in the elderly diabetic. Effect upon fasting glucose, oral glucose tolerance tests, blood pressure, lipids and HbA1c is also useful. Abdominal girth, skin-fold thickness and body fat measurements can be motivational. But we should also be looking at softer measures like:
lcompliance with the programme
linfluence on other family members
lquality of life
The last thing to write is the business plan. This will include the realistic costs of providing the service set against any direct financial savings for the PCT (such as through reduced laboratory costs, hospital referral) and possible long-term cost benefits.
It may also include a reasonable profit for the practice a concept with philosophical implications quite novel for the NHS.
1 Wolf AM, Colditz GA. Current estimates of the cost of obesity in the United States. Obes Res. 1998;6:97-106
2 Department of Health. CMO's Update 26, May 2000
3 Pan XR et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance:
the Da Qing IGT and diabetes study. Diabetes Care 1997;20:537-4
4 Tumoilehto J et al. Prevention of type 2 diabetes mellitus by lifestyle among subjects with impaired glucose tolerance.
N Engl J Med 2001;344:1343-50
5 Sjostrom et al. The Xendos Study. 9th ICO, Sao Paulo 2002. Poster Presentation