“Obesity is the new smoking”, said Simon Stevens, Chief Executive of NHS England. “It is a slow-motion car crash in terms of avoidable illness and rising health care costs.”
Is he right? And if so, can the NHS help work towards solutions, or only tackle the associated health need?
How big a problem is the obesity epidemic?
According to estimates from Public Health England, two thirds of adults and a quarter of children between two and 10 years old are overweight or obese. Obese children are more likely to become overweight adults and to suffer premature ill health and mortality, and by 2034, 70 per cent of adults are expected to be overweight or obese. This challenge will not go away.
As for the financial consequences of obesity for the NHS, Simons Stevens puts it eloquently: “If as a nation we keep piling on the pounds around the waistline, we’ll be piling on the pounds in terms of future taxes needed just to keep the NHS afloat.”
Obesity increases the risk of a number of health issues, including heart disease, diabetes, musculoskeletal disorders, cancers, depression and anxiety. Severely obese individuals are three times more likely to require social care than those with a normal weight, resulting in increased risk of hospitalisation and associated health and social care costs.
Estimates suggest obesity cost the NHS £5.1 billion in 2006/07, including obesity medication, the increasing use of bariatric surgery and new equipment to accommodate larger people. This is more than the £3.3 billion attributed to smoking related ill health and £3.3 billion attributed to alcohol related ill health. In addition obesity costs social care a further £352 million in extra hours of help.
How do we stop ‘piling on the pounds’?
Obesity is a consequence of numerous factors from genes, diet, levels of physical activity, and the surrounding environment, as well as social and cultural factors.
To tackle obesity, a previous government-funded report suggested a system-wide approach is necessary. It should address everything from the production and promotion of healthy diets to the redesigning of the built environment to promote walking, together with wider cultural changes to shift societal values around food and activity.
Are the solutions beyond the remit of the NHS?
In April 2013, local governments became responsible for improving the health of their population supported by the public health grant and specialist public health teams. Public health professionals have been influencing local planning, encouraging the development of walking and cycling routes, areas for sport and recreation and the regulation of food outlets by schools.
Tackling the wider determinants of obesity may not be the primary responsibility of the NHS, but in view of the challenges the obesity epidemic poses, the NHS needs to prioritise obesity prevention. The NHS has three distinct roles in obesity prevention: supporting patients and populations to change behaviour; as an employer; and as an advocate to drive local and national change.
Supporting patients and populations to change behaviour
Last week, NHS England launched a national diabetes prevention initiative referring adults at high risk of diabetes to lifestyle change programmes. Local authorities, in partnership with general practice, already undertake health checks and offer high risk individuals referral to behaviour change programmes. There is good evidence to support these interventions, but weight is a sensitive issue. Patients do not appreciate discussing their lifestyles with their GPs, and this makes health care professionals reluctant to talk about these socially awkward topics.
The system does not encourage health care professionals to prioritise health promotion. The Quality and Outcomes Framework (QoF) incentivises general practitioners to note obese patients on a register; however there is no monitoring of people in progression to become obese, no monitoring of how the register links to lifestyle interventions and the uptake or outcome of these interventions. A diagnosis of obesity is rarely recorded in reports from hospital admissions or outpatient attendances , suggesting that it is not considered relevant. The system needs to facilitate a change in the mind set of health professionals.
As an employer
The NHS is the largest employer in the UK, employing more than 1.35 million staff, 700, 000 of whom are either overweight or obese.
A recent audit on whether NHS trusts were healthy working environments by the Royal College of Physicians showed that only 28 per cent of trusts had an obesity plan, two thirds did not offer healthy food options for staff working irregular hours, and many had poor access to health promotional activities. Healthy staff are more productive and have less days off sick, yet 50 per cent of trusts audited failed to make the link between health and wellbeing and long term sickness.
Recently, Simon Stevens also announced a new pilot programme for Imperial NHS staff that encourages overweight NHS staff to volunteer for onsite weight management programmes . A third of hospital trusts are also trialling similar health promotion strategies.
The initiative at Imperial NHS trust is a good start but may not go far enough. It only focuses on individual behaviour and does not consider the bigger institutional changes that need to be made to create a healthy working environment. What about also improving the quality of food outlets on the hospital site, implementing reasonable working schedules, regular meal break times and initiatives that promote active travel to work? The NHS has a hugely important role in setting the example to other organisations and its patients.
As an advocate
In addition to pushing boundaries in how the NHS incorporates obesity prevention into its core business, the NHS is a powerful national player that can partner with Health and Wellbeing boards locally, Public Health England and other independent bodies to influence change at a societal level. The NHS cannot afford to wait for others to lead change, it needs to be demanding more action from national and local government, industry and media, as well as improving how it operates.
The NHS is an influential part of the system
Obesity is complex and many of the causes appear to be beyond the scope of the NHS. The NHS has a huge challenge ahead of it to address the consequences of obesity. This should not distract from the urgency to improve prevention. We will not solve obesity without strong local and national advocates. NHS England’s announcements of new prevention initiatives are welcome, but we need bigger and bolder actions if we are going to turn the tide of this epidemic.