Obesity: patchy delivery of healthcare

Designed to confront the current problems with delivery of multidisciplinary services for patients developing complications of obesity, the Royal College of Physician’s Action on Obesity report1 took over nine months to prepare. Professor John Wass explained further: “We starting by ascertaining the presence, or absence of, current multidisciplinary bariatric services in secondary and tertiary care in the UK. We sent questionnaires to a number of different learned society members and received 122 responses from across the UK which were then analysed.” The report identified large variations in the way obesity is treated across the country, with the rate of hospital bariatric procedures, such as gastric banding, ranging from 0.4 per 100,000 in some Primary Care Trusts, to 41.3 per 100,000 in others. Prof. Wass highlighted some of the key findings of the report. He said: “One of the main figures to come out of the report is that only 37% of patients in the UK are able to rely on a multidisciplinary bariatric team for care, which means that many people with severe diabetes, hypertension and other secondary morbidities do not have a source for correction of their primary problem – obesity. Also, only a very small proportion of the report sample (17%) benefitted from a proper inpatient team.” The growing numbers of people with severe and complex obesity are those who are the most likely to have associated, multiple medical, psychological and social problems and make the input of multidisciplinary teams (MDTs) invaluable. Indeed, the importance of a multidisciplinary care approach to obesity and its complications has been emphasised by several guidelines, including those produced by NICE2 and the Scottish Intercollegiate Guidelines Network (SIGN).3 MDT meetings allow information and knowledge sharing, more complete patient assessment, greater informed patient and treatment selection, and formulation of individualised treatment plans and follow-up.4 Evidence supporting multidisciplinary care is better established and the practice is most widely embraced in cancer care.4-6 Effective multidisciplinary patient care for the obese patient should be implemented as early as possible at least to screen for and diagnose obesity-associated diseases and prevent obesity progression, and ideally, to reverse the obesity and ensure optimal management of any complications of obesity. This requires the multidisciplinary approach to start in primary care, with more complex cases being catered for within specialist weight management services. Patients requiring bariatric surgery should be managed in accredited centres. Specialist weight management services are essential for severely obese patients as they tend to have more complex problems. Currently there are two patterns of entry into such specialist MDT care, usually determined by commissioning strategies: surgical, through bariatric surgery assessment pathways; or physician led. While both patterns need a full range of healthcare professionals, the report suggests that an initial physician-led assessment pathway2 is the most appropriate route, in view of the need to fully address the medical issues behind and consequent to the patient’s obesity. The specialist MDT needs expertise in multiple obesity-related disorders.7 The MDT should include specialist consultant physicians, dietitians, nurses and psychologists and psychiatrists. An MDT fully integrated into surgical treatment pathways will include bariatric surgeons, specialist anaesthetists and links to haematology for advice on thromboprophylaxis.

Setting up an MDT

The RCP believes it is in a good position to encourage, train and oversee the development of these vital multidisciplinary services and the report provides clear guidelines as to how these can be set up and operate, as well as sample care pathways. “We believe that multidisciplinary services should be set up around the country, led and accredited by the RCP,” said Prof. Wass. Such a group, says the report, could oversee the development of these services as well as, in the future, providing scientifically sound evidence-based advice to Government on various pertinent issues in the obesity debate.