Government's u-turn on essential funding for obesity is putting more lives at risk

Supporting treatment of obesity

In March 2021 news that the government had unexpectedly agreed a budget of £100m for one year to support action on obesity primarily focused on supporting the treatment of obesity, appeared to be shock to many stakeholders, (local authority commissioners, service providers like MoreLife, and patient representative groups like Obesity UK. There was no indication that this money was coming given obesity strategies for the last 15 years had focused on reducing expenditure on treatment and focusing on preventative approaches.

At this point it is important to note that despite obesity being recognised as one of the most expensive public health issues costing our economy £27bn per year, there has been minimal investment at both central and local government level given over a decade of austerity.

Experience of accommodating investment

Whilst, of course, this investment in obesity is welcome, it also posed significant challenges to the key system stakeholders involved in ensuring effective support for our population and best value use of scare public funds. My experience during this period whilst interacting with stakeholders was:

•  Many local authorities were not ready. They did not have intervention programmes in place, or did not have any plans to implement such activities in the short or medium term. Through years of underfunding or use of scarce resources on alternative non-obesity related local priorities, there was a major gap in the infrastructure needed for effective use of these resources. Many local authorities explored the opportunity to think in a more sustainable way; to innovate; to address health inequalities; or to develop specialist programmes for key vulnerable groups where evidence is less prominent (younger children, men, those with disabilities, or children with special educational needs). However many of these plans were overly ambitious both in terms of time, impacts and cost, there was limited understanding of the very specific needs of these important groups, not to mention the time permitted to undertake important coproduction with them, all within the short-term commitment of one year funding (at the time). 
• The Office of Health Inequalities and Disparities seemed surprised by the investment and quickly responded with frameworks to assist in the dissemination of the resources and actions to support implementation. However, many of these important activities (monitoring systems, guidance around intervention models etc.) led to additional infrastructure pressures on an already weak infrastructure within a time-sensitive situation.
• As a provider we didn’t understand the rules of engagement. The clock was ticking, and although local authorities were rightly responding proactively, this action ended up being uncoordinated and highly reactionary in the absence of time to develop a robust plan locally or centrally. As a provider we received many calls for support, there was no real clarity on how much money was available, for what outcomes, and many local authorities didn’t know what to do. In reality £100m was dispersed across a number of activities, and therefore actual contract size was small - making many of them economically unviable. Opportunities to pool funds from several local authorities, enabling economies of scale, was limited by the varied approaches and timelines involved. Despite providers holding much of the knowledge and skills of implementations they were not consulted.  The fragility of the market, due to years of underfunding, was probably not appreciated either.
• Obesity UK, as a member organisation for people living with obesity, was also confused by the commitment and its impact on its members. Many questions on the forums were asked about support and access to weight management services that were either not available to them locally, or not appropriate for their needs. There was uncertainty about COVID and how people living with obesity were recognised as vulnerable, which made them consider the risks and benefits of participation.  Figures such as £100m seem a lot of money, but in relative terms the figures are small (the actual figure was £30m for service provision, with 2 in 3 adults (30m) and 1 in 3 children (3.5m) suffering from excess weight or obesity it is clear this money is not significant. Obesity UK has long reported the lack of services provision through Local Authorities and Clinical Commissioning Group’s, and the postcode lottery of service provision as a common theme in its 25,000 members forums. Therefore this money and news fuelled both hope and confusion. 
• Finally, there seemed to be little consideration of the impact COVID had on public health and the NHS systems when these plans were conceived. It was 2021 and COVID remained a pandemic with significant national impact, there were very long waiting lists, many of the community health services having stopped their contribution to the weight management support pathways due to their need to focus on COVID and there was limited capacity in the system - all factors that undermined the successful utilisation of these resources.

Everyone knows quick fixes to weight problems don’t work

A fundamental issue with the £100m plan was the lack of appreciation that obesity is a chronic relapsing and remitting disease, and well-designed intervention programmes cannot be short term in nature, they are complex: reflecting the complex needs of people who live with obesity.  The poor implementation of this programme highlights a lack of understanding of what it takes to deliver effective intervention programmes that reflect the needs of people living with obesity. Some important factors include:

• Clinically safe & effective - Services and a client journey must be co-designed with clients needs met through a person centred approach and utilisation of evidence, with access to the necessary resources to deliver accordingly.
• Appropriate marketing & communications - Raising awareness of high quality service availability in local communities without increasing stigma. This includes cutting through the poor/contradictory messages or quick fix offers that have minimal chance of success or are potentially damaging.
• Recruitment and training of team members – Unfortunately there is limited capacity in the system and certainly not at short notice to access and appropriately trained expertise like Doctors, Dietitians, psychologists, exercise professionals to meet the needs of people living with obesity.
• Quality client experience – Ensuring clients experience a high-quality service, including quick and convenient appointments and service offers in facilities appropriate for clients (considering transport links, accessibility of the building, chairs suitable for clients…) 
• Fitting into complex client pathways – Services are typically 12-52 weeks in duration, and many people with obesity access other healthcare support. Therefore short term funding that may disappear creates unpredictability into the care pathway and it is highly disruptive for clients and professionals.
• There is a weak infrastructure due to decades of poor funding - the minimal funds that are made available nationally, the annual shrinking budgets alongside increasing volumes expected by local Public Health commissioners, requiring ongoing innovative working and thinking.  This is at a time that bureaucracy has increased significantly.  All have led to challenges to the infrastructure that support responsive and efficient service delivery.  Additionally, given the uncertainty of ongoing COVID responses, digital infrastructure enabling varied and responsive forms of support was and still is a necessary development, however it all requires funding which was not available.

Then the amazing news came that the £100m per year would be extended for a further 3 years. Our thoughts were 'wow, maybe government was finally taking obesity seriously', even as the public purse is stretched, and also the reality of the strong relationship with COVID severity and obesity, that a mindset of a government committed to public health was finally here. We, like many organisations, began the planning to contribute to this programme of work, we had more time, we had the opportunity to work with local authorities and the emerging Integrated Care Systems to adequately plan, consult clients, overcome short term challenges and deliver high quality care /support for people living with obesity and begin to turn the tide of the ‘Unhealthy Britain’. Fundamentally we could focus on effective care and best use of scarce public funds.

Another big government U-Turn

However, on 1 April, a letter from OHID delivered the devastating news that government were doing a U-turn on this commitment. This was one day into the financial year, many local authorities had made plans and providers were already investing in people and systems to support more people living with obesity across England. Words cannot express the frustration and disbelief - could this government really be so out of touch with reality and the needs of its people, as well as a view of the crippling societal impact of obesity that report after report outlines?

Our teams were devastated with the u-turn, as were our partners. They had worked incredibly hard in a highly responsive way of supporting and co-developing programmes for/with underserved groups (those with learning disabilities, physical disabilities, carers and those with mental health issues) as well as other target and underserved groups. The impact of this u-turn is that these vulnerable groups will be left again with little support, thereby widening, not narrowing, health inequalities.

The evidence of the relationship between deprivation, food insecurity and obesity is clear and has been very clear for decades. The National Child Measurement Programme data from November 2021 showed the significant impacts of COVID on obesity rates in our children, mirrored in our adults too. Surely this government must realise that this u-turn will now lead to rises in obesity, compounded by the current cost of living crisis?

This government has talked about its “world leading obesity plan” but in effect it only has a document with words and commitments. Even the National Audit Office questioned their plan “The government will need to act with greater urgency, commitment, co-ordination and cohesion if it is to address this severe risk to health and value for money.” The short-sightedness of this further u-turn will be felt in the lives of millions of people and our health care systems for decades to come. Whilst we appreciate it’s futile, we still call for the £100m investment to be reinstated for the sake of our nations health and welfare.