Are Tier 3 Obesity Services meeting local clinical needs?

Problem

In April 2014 commissioning tier 3 obesity services became the exclusive responsibility of Clinical Commissioning Groups, having previously sat with NHS England. Tier 3 services comprise primary or community care-based multi-disciplinary teams providing intensive individualised interventions to patients including, but not limited to, behaviour change strategies, physical activity promotion, dietary advice and support including low calorie and very low calorie diets, psychotherapy, and pharmacotherapy. From the outset, concerns were raised about the variation in commissioning of services and lack of provision in some areas.In 2015, Public Health England attempted to map tier 3 services using a mixed methods data collection approach which included electronic surveys sent to all local authorities and CCGs, and face-to-face mapping workshops in selected areas; this was met with a poor response (41%) and hence provided an incomplete picture.

Approach

We took an alternative approach to data collection: Freedom of Information requests were sent to all 208 CCGs in England in September 2016 requesting information about their tier 3 services, including service provider, commissioning arrangements and referral rates. This resulted in a 96.6% response rate (201/208 CCGs). The information provided was analysed in conjunction with contemporaneous CCG level data regarding population size and obesity rates, which was publically available from NHS Digital.

Findings

201 CCGs responded, including 11 who believed tier 3 was still the commissioning responsibility of NHS England. At the time of the request, 135 (68.2%) CCGs commissioned tier 3 services, six were in the process of commissioning a new service and three were decommissioning their services. 39 (19.7%) CCGs reported having no tier 3 services. Of those with a tier 3 service, most used an NHS provider (97/135; 71.9%), followed by private providers (37/135; 27.74%) or the local council (1/135; 0.7%). Commissioning (or not) of a service was not related to CCG population size or local obesity rates. Between CCGs, referral rates ranged from 1.1 to 503.8 patients per 100,000 population. Referral rate was not correlated with local obesity rate nor was there any difference in referral rate by service provider type.

Consequences

Provision of, and referral to, tier 3 services across England is variable and does not appear to be based on local clinical need resulting in a postcode lottery for patients seeking treatment, which in turn risks widening health inequalities experienced by those who cannot afford to self-fund treatment. As obesity is a major risk factor for a number of diseases, commissioning and use of services needs to remain a clinical priority. The fact that some CCGs reported decommissioning services paints a worrying picture for the future. CCGs need to invest in services and encourage referrals now in order to save costs and achieve better health for patients in the future.