News analysis: Obesity - private clubs help PCTs achieve the figures they want

Referring overweight patients from GPs to the independent sector is a controversial approach but for many, joining a commercial group proves more effective in losing weight than drug treatment. Tash Shifrin reports on how 'slimming on referral' is working

'I'll start my diet tomorrow.' Millions of people must have said it with a wry smile, and the translation is widely understood: the speaker is highly unlikely to start their diet tomorrow.

But for those who need to lose weight for health rather than cosmetic reasons, the problem of how to achieve this is a serious one. It is also a problem that confronts the NHS. The Choosing Healthwhite paper put the situation in stark terms: 'Trends in diet and lifestyle over the last three decades have combined to bring an epidemic of obesity.'

The white paper spelled out that it was time to 'act on obesity as an issue in its own right', and promised guidance from the National Institute for Health and Clinical Excellence. But tucked away amid a string of other measures to tackle obesity was a little passage that suggested a new player could be entering the public health field as part of the anti-obesity drive.

'The independent sector may have a key role in providing effective behaviour change programmes in ways that are more acceptable than traditional NHS care to some groups of patients,' the document said.

Slimming club involvement

Of course, the growing role of the private sector in the NHS is not new: it is a tenet of Tony Blair's government. But the commercial organisations now hovering around the NHS are not just the increasingly familiar big healthcare corporations with their private hospitals and orthopaedic surgery centres, but organisations offering slimming clubs and classes, too.

Mr Blair took the chance to bestow the prime ministerial smile on his latest private sector friends during a speech on public health in July, sharing a platform with Caryl Richards, managing director of Slimming World. The organisation runs thousands of slimming groups, and in some parts of the country has already struck deals with the NHS to set up 'slimming on referral' schemes.

The Department of Health says there is no national scheme planned - because it is up to primary care trusts to make their own decisions. But the interest of Downing Street suggests this is an idea we may hear more of.

'We are in discussion with Number 10 and we have regular discussions with the DoH, via Tabitha Jay [the department's obesity programme manager],' confirms Jacquie Lavin, Slimming World's nutritionist and partnerships manager.

She explains that Slimming World offers participants a healthy eating system with an emphasis on 'free foods' such as pasta, fish, fruit and vegetables, which can be eaten in unlimited quantities - and a course of weekly groups, where participants are offered support and encouragement to lose weight and live a healthier lifestyle.

Slimming clubs on the NHS

The idea behind slimming on referral is that GPs can refer appropriate obese patients for Slimming World courses, giving them a voucher that allows them to attend a 12-week course for free, with the tab picked up by the NHS. Slimming World offers a subsidised rate to the NHS, with PCTs paying£44.50 per patient for 12 weeks - a saving of around 25 per cent.

Ms Lavin says the idea originated in discussions with the former South Derbyshire health authority six years ago. 'The idea of slimming on referral came from the GPs. They had recently started exercise on referral in Derby and it seemed to be working,' she says. With Slimming World based locally, and the HA lacking resources to 'reinvent the wheel' on its own account, a joint pilot scheme was set up in September 2001.

An evaluation published in this month's Public Healthjournal found that of 107 patients with a body mass index of more than 30 who were referred to Slimming World for a free 12-week course, 91 attended the group, with 62 completing the full 12 weeks. Participants lost an average 5.4kg, or 6.4 per cent of their starting weight.

After the first 12 weeks, 47 patients chose to continue, funding themselves, with 34 completing a further 12 weeks. On average they lost 11.3 per cent of their starting weight.

The scheme is no longer running in Derby: five years and three NHS reorganisations later, it is unclear why the successor primary care bodies chose not to continue with it.

But 13 other PCTs have since launched pilots or, in some cases, full schemes of their own. At East Suffolk PCT, Norman Foster, acting consultant in the public health team, explains that slimming on referral was piloted at two GP practices, with around 60 patients taking part.

'The results we got back were very encouraging,' he said, with 49 per cent of the patients referred to Slimming World losing a minimum of 5 per cent body weight. Both the results and costs were 'at least as good, if not b0etter' than drug treatments for obesity, he added.

The PCT and its West Sussex neighbour have now moved to introduce the scheme across the county. 'We've top-sliced our budget to do this and take-up has been absolutely brilliant. In two weeks, we've got 19 of our 44 practices signed up. By the end of September, I'd have thought we would have most practices doing it,' says Mr Foster.

'This is a lifestyle change'

The GP practices are using 'a simple commitment tool' to assess whether patients are really committed to following the course, and patients are usually those with a BMI of 30 or over. The PCT has bought an initial 1,500 courses for its patients.

'Slimming World sends the data back to the practice with the patient's permission - they sign consent forms - and the PCT gets anonymized data,' says Mr Foster.

He adds that slimming on referral avoids the side effects of drug treatment regimes but offers a long-term effect: 'The good thing is this is a lifestyle change.'

Local GP Dr Louise Skioldebrand says: 'It's a great facility to have. One of my patients is completely evangelical about it. If someone wants to do something about their weight, it's nice to be able to offer a range of solutions.'

But she adds that not all obese patients are keen. 'A lot of people say they've been there, done that and they don't want to do it.'

Elsewhere, other PCTs are piloting the scheme. A spokesperson for North Tees PCT explains that a nurse practitioner piloted the Slimming World course with 20 patients, initially targeting men. This 'met with varying degrees of success, although one male diabetic patient did lose around two stones and his medication was reduced as a result'.

She adds: 'Another lost weight but other complications with his health meant he could not continue with the full course. Other male patients, however, just did not want to attend Slimming World courses.'

A full evaluation has not yet been completed, and a decision on whether to offer the scheme in future has not yet been made, the North Tees spokeswoman says.

James Williams, deputy director of public health at Huddersfield Central and South Huddersfield PCT, which is also running a pilot, says: 'You have to provide an intervention suited to the individual. For some people, working in a social environment can help.'

His PCT is looking at slimming on referral to supplement an existing exercise scheme. 'Slimming World, Weight Watchers, Rosemary Conley - all these organisations are there already.'

It is a question of whether the PCT can 'capitalise on that pre-existing tool', he says. 'It did have evidence that suggested it worked. It's been peer-reviewed.'

The Huddersfield pilot involves two practices and has been running for around four months. The PCT is not looking to review results until the end of the year.

'I want to see, does the weight stay off and is it cost-effective?' Mr Williams says. 'I want to see the long-term view, what the fallout rate has been and what value it's had in reducing our targets.'

Providers of choice

Middlesbrough PCT has funded weight management courses from different providers for 750 obese patients in a scheme that has been running for a year. Lifestyle co-ordinator Will Smith says: 'We needed to fill a gap. Obesity was a massive problem in Middlesbrough. Weight Watchers and Slimming World said they could offer a service on reduced rates to the PCT.

'They've got a very good background in weight loss and both provided very good data. We also use Balance, a local authority scheme designed by dieticians. We ask patients to choose [between providers] themselves, with guidance from the GP or nurse.'

The PCT is currently rejigging its evaluation criteria so results are not available, but Mr Smith says: 'I'm very happy with it. We're offering a service for people who might not have been able to find the insightful support they need.'

Dr Alan Maryon-Davis, cardiovascular health and obesity spokesperson for the Faculty of Public Health, says slimming on referral 'has got potential', as part of a pathway of measures to tackle obesity. 'We do see there's a role for commercial organisations on that pathway,' he says.

'These organisations are highly experienced in dealing with slimming issues, have a good understanding of the psychology, and on the whole are very professional.' Compared with drug treatments, he says: 'If you can achieve lifestyle changes through diet and exercise, that's infinitely preferable.'

But he adds: 'We wouldn't want widespread use of commercial organisations at the expense of good local exercise and dietetics services. It's not an either/or.'

He also stresses that PCTs should choose with care and build monitoring and evaluation into contracts.

Dr Maryon-Davis predicts that the tie-up with Slimming World could be just the start of a wider involvement of commercial organisations in public health. 'Exercise, dietary advice, smoking cessation - I'd expect the market to open up,' he says.

The slimmer's tale

Sue Evans was offered a referral to a Slimming World course in Stowmarket, Suffolk by a practice nurse at her GP surgery after moving to the area. Her husband Brian was also referred.

'I went for a general check-up and saw the nurse. I said: ?Don't tell me about my weight...?

'I'd been meaning to do something. I'd tried all sorts of diets - I knew I needed to lose weight, but there wasn't the trigger to make me do it. I'm sure I would have put it off forever.

'I think it's an excellent, excellent idea. It's been a success for me. People say, ?How can you justify the cost [on the NHS] - why should we pay??, but when I started, I was on medication for high blood pressure. Now my weight's dropped, my blood pressure is normal - I don't even need to get it checked any more.

'My mum has age-onset diabetes, she's very overweight and I probably would have gone that way myself.

'In the first 12 weeks, me and my husband lost two stone each, so we kept going. Since February 2005, I've lost 6.5 stone.

'We're now healthier as a family. My daughter has never been obese, or as overweight as we were, but she's gone down a couple of dress sizes - because she eats what we eat. It's really changed our lifestyle. We all exercise now and we couldn't before.'