Amy CroftMichael Pittilo Student Essay Prize

Fat Chance – With obesity set to reach epidemic proportions in the UK – how might improved patient-centred care reduce the burden it poses to the NHS?

Introduction

Recent data suggests that one in four adults in the UK is clinically obese1. This figure is predicted to rise to 60% by 2050 2. Childhood obesity is also rising, and with this comes increased health complications later in life, alongside significant psychosocial sequellae.With more cuts being made on NHS budgets, how will the NHS will cope with the health problems that such high levels of obesity will create? Obesity is a major risk factor in cardiovascular disease, diabetes, musculoskeletal disease and some cancers 3. Taking these conditions into account, it is estimated that the annual cost to the NHS is £3.23 billion 4. There has been little evidence so far to prove the efficacy of current interventions to combat this problem 5.

It is recommended that obesity is managed with lifestyle advice, and in certain circumstances, medication and surgical treatment6. If obesity levels rise by more than double, as predicted, it is unlikely that the NHS will be able to produce the resources needed to effectively manage obesity and the health problems it creates. The NHS must act now, alongside the government and food industries to curb this epidemic before it is out of our control.

The importance of the patient-centred approach

The social determinants of health are coming to the forefront of many worldwide health debates. Health is about more than the biological. Biomedicine underlies modern healthcare practice in the UK and its importance is paramount in the NHS, but it should not cause us to neglect looking at other influencing factors. It is the patient-centred approach which can bring these issues to light, so that a full picture can be used to treat a patient effectively.

Levels of obesity are rising due to a plethora of factors involving the epidemiological and nutritional transitions occurring in the UK and around the world. These include increasing sedentary lifestyles, urbanization, and the so-called ‘obesogenic’ environment 2. Much research and campaigning (for example, see the government’s ‘Change4Life’ campaign7) has thus far focused on prevention and wide-scale reduction in obesity levels. However, with over one quarter of the population already struggling with a Body Mass Index of over 30, services must be improved to help those already affected.

Spending time in specialist childhood obesity clinics as a medical student reinforced my view that the reasons for each individual’s weight problem is highly person-specific. One child might be struggling with bullying, another with a broken family, and more still with parental factors such as poor food education. Obesity is much more than a biomedical problem. It is a society-wide biological, psychological and social issue. A holistic view must be taken to determine the causal factors in an individual’s lifestyle in order to fully and sustainably reduce weight. A clinician cannot simply tell a patient to diet and exercise and expect to see results.

This is where the patient-centred approach is absolutely vital. It sees the patient at the heart of care, directly involved in the decision-making process in partnership with all healthcare professionals involved. This means that the NHS must provide a person-specific, multi-disciplinary approach with a high focus on the doctor-patient relationship.

One size does not fit all

A patient-centred approach adopts the attitude that patients are individuals with hugely diverse circumstances. The complex nature of obesity means that each person will have different reasons and influencing factors for their weight, and these must be explored in order to tackle the problem. One child I met was struggling with her weight because one parent was encouraging her to diet, and the other parentwith whom the child lived for half of the week, was constantly giving her treats. Other parents were struggling to find fresh fruit and vegetables in their local area, unsure how to cook healthy food, or did not have the time or financial resources. This is not a problem which can be solved by generalised diet and exercise advice. Individual circumstances require specific advice and treatment. The NICE guidelines for management of obesity recognise this, and state that treatment and care should take into account individual needs and preferences6.

The therapeutic doctor-patient relationship

The doctor-patient relationship is a key aspect of patient-centred care. A physician or other healthcare professional must be able to communicate effectively and build a relationship of trust with their patient. The General Medical Council (GMC) states that a relationship based on openness, trust and good communication will enable a doctor to work with their patient and their individual needs 8. Patient’s beliefs and views of their own health and treatment must be taken into consideration when deciding a treatment plan. The doctor-patient relationship can be a therapeutic tool to provide exploration of the patient’s views, as well as support, motivation and advice.

The Multi-Disciplinary Team (MDT)

Many healthcare professionals are involved in the care of patients with obesity. General practitioners, specialist doctors and nurses, physiotherapists, occupational therapists and dieticians all play a vital role. A patient-centred approach will allow effective communication and co-ordination of services to ensure the patient has access to all the services that are available to them.

Moving towards a patient-centred NHS: A Model for Care

The patient-centred approach to obesity management can therefore be considered to take an individual and holistic format, using both the therapeutic doctor-patient relationship and a MDT approach. This approach can be demonstrated using the model I have developed in Figure 1.

Figure 1: The patient-centred approach to obesity management.

The outer box of the model represents the NHS as a system. The patient is at the centre, surrounded by their family, primary care and secondary care. The biological, social and psychological factors influencing health are represented by block arrows penetrating each layer of the model.

This model represents the central role of the patient in the care pathway; they have autonomy in the decision-making process and are in control. The influence of the family is highly important here. Family and friends are likely to be the first point of help-seeking behaviour. I have seen in my experience that a patient’s family can both restrict and aid the help-seeking process in healthcare, and will have a significant influence on the patient’s decisions and health beliefs. The model shows each unit (family, primary care, secondary care) connecting and communicating around the patient. Each unit should take into account all of the biological, psychological and social determinants of health specific to their individual patient.

If patients are managed effectively, at initial contact, there is potential to curb any future obesity-related health problems the patient may experience, thus reducing the future burden on the NHS. This can be done on a practical level by ensuring continuity of care and communication with healthcare providers, enabling greater patient and family participation in decision making, and providing the patient with support to self-manage their care 9.

An example of this in practice is the Counterweight Programme (see Case Study Box). Of those who attended the programme for 12 months, over 30% had maintained ≥5% weight loss. This is associated with significant prevention of comorbidities, in particular, cardiovascular and metabolic risk factors10,11.

Conclusion

Obesity levels are rising at an alarming rate in the UK. This increase is due to a variety of factors, including poorer diets, reduced exercise, increasingly sedentary lifestyles, urbanization and the ‘obesogenic’ environment. Obesity and the health problems it is associated with, presents a significant burden to the NHS already. If levels continue to increase, the NHS may struggle to cope. This will have negative implications for the whole of the NHS and the wider society, as resources which could be used to meet other healthcare needs would be taken up by this epidemic. Obesity is a condition which is affected by biological, psychological and social factors. It is for this reason that a holistic, patient-centred approach is required when managing these patients. This means that each patient should be viewed as an individual with specific needs. These causal factors should be explored within an open, honest and trusting doctor-patient relationship and the obesity and its complications managed with a MDT approach. The patient must be at the very centre of their care, in control and involved in the decision-making process, with thorough communication at all levels. It is by improving the patient-centred approach that the NHS can meet patient’s needs effectively, taking into consideration their beliefs and perspective. Alongside wider public health and governmental initiatives, the patient-centred approach is key to tackling obesity on a real, person-specific level, and thus improving health outcomes reducing the future burden on the NHS.

References

  1. Department of Health. Obesity. 2011.Available at: last accessed 24/04/11
  2. Tackling Obesities: The Foresight Report and implications for local government??
  3. World Health Organisation. Factsheet on Obesity and Overweight. 2011. Available at: last accessed 24/04/11
  4. Allander S, Rayner M. The burden of overweight and obesity-related ill health in the UK. Obesity Reviews 2007; 8:467-473
  5. Jain A. Fighting Obesity. British Medical Journal. 2004; 328: 1327
  6. National Institute for Clinical Excellence. CG43: Obesity: quick reference guide 2 for the NHS. January 2010
  7. National Health Service. Change4Life. 2011. Available at: last accessed 25/04/11
  8. General Medical Council. Good Medical Practice: The doctor patient relationship. 2011, available at: last accessed 24/04/11
  9. Bergeson SC, Dean JD. A Systems Approach to Patient Centred Care. Journal of the American Medical Association, 2006; 296 (23): 2848-2851
  10. The Counterweight Project Team. Empowering primary care to tackle the obesity epidemic: the Counterweight programme. European Journal of Clinical Nutrition, 2005; 59: Suppl1, S93-S101
  11. The Counterweight Project Team. Evaluation of the Counterweight Programme for obesity management in primary care: A starting point for continuous improvement. British Journal of General Practice, 2008; 58: 548-554

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