Common use of Population Needs Clause in Contracts

Population Needs. 1.1 National/local context and evidence base Obesity and overweight are a global epidemic. The World Health Organisation (WHO) expects that approximately 2.3 billion adults worldwide will be overweight by 2015 and more than 700 million will be obese. The prevalence of obesity in England is one of the highest in the European Union. In England: Just over a quarter of adults (26% of both men and women aged 16 or over) were classified as obese in 2010 (Body Mass Index (BMI) 30kg/m2 or over). Using both BMI and waist circumference to assess risk of health problems, 22% of men were estimated to be at increased risk; 12% at high risk and 23% at very high risk in 2010. Equivalent figures for women were: 14%, 19% and 25%. There has been a marked increase in the proportion (doubling) that are obese, a proportion that has gradually increased over the period from 13.2% in 1993 to 26.2% in 2010 for men and from 16.4% to 26.1% for women. BMI Definition BMI range (kg/m2) Underweight Under 18.5 Normal 18.5 to less than 25 Overweight 25 to less than 30 Obese 30 to less than 40 Obese I 30 to less than 35 Obese II 35 to less than 40 Morbidly obese/obese III/severe 40 and over Overweight including obese 25 and over Obese including morbidly obese 30 and over Obesity is directly associated with many different illnesses, chief among them insulin resistance, type 2 diabetes, metabolic syndrome, dyslipidaemia, hypertension, left atrial enlargement, left ventricular hypertrophy, gallstones, several types of cancer, gastro-oesophageal reflux disease, non-alcoholic fatty liver disease (NAFLD), degenerative joint disease, obstructive sleep apnoea syndrome, psychological and psychiatric morbidities. It lowers life expectancy by 5 to 20 years. Direct costs of obesity are estimated to be £4.2 billion (Department of Health). As BMI increases the number of obesity-related comorbidities increases. The number of patients with ≥ 3 comorbidities increases from 40% for a BMI of < 40 to more than 50% for BMI 40-49.9 to almost 70% for BMI 50-59.9 and ultimately to 89% for BMI > 59-9. The treatment of obesity should be multi-component. All weight management programmes should include non-surgical assessment of patients, treatments and lifestyle changes such as improved diet, increased physical activity and behavioural interventions. There should be access to more intensive treatments such as pharmacological treatments, psychological support and specialist weight management programmes. Surgery to aid weight reduction for adults with morbid/severe obesity should be considered (when there is recent and comprehensive evidence that) an individual patient has fully engaged in a structured weight loss programme; and that all appropriate non-invasive measures have been tried continuously and for a sufficient period; but have failed to achieve and maintain a clinically significant weight loss for the patients clinical needs (NICE CG43 recommendations). The patient should in addition have been adequately counselled and prepared for bariatric surgery. This surgery, which is known to achieve significant and sustainable weight reduction within 1-2 years, as well as reductions in co-morbidities and mortality, is commonly known as bariatric surgery. The current standard bariatric operations are gastric banding, gastric bypass, sleeve gastrectomy and duodenal switch. These are usually undertaken laparoscopically. Bariatric surgery is the most effective weight-loss therapy and has marked therapeutic effects on patients with Type 2 diabetes. The economic effect of the clinical benefits of bariatric surgery for diabetes patients with BMI 35 kg/m2 has been estimated in patients aged 18-65 years. Surgery costs were fully recovered after 26 months for laparoscopic surgery. The data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI of ≥35 kg/m2. Other groups have been less well studied but bariatric surgery is reported to be cost effective against a wide range of co- morbidities. Bariatric surgery is a treatment for appropriate, selected patients with severe and complex obesity that has not responded to all other non-invasive therapies. Within these patient groups bariatric surgery has also been shown to be a highly cost effective therapy that prevents the development of co-morbidities. Bariatric surgery in the North West services will require that these patients fulfil the criteria within this specification. Selection criteria of patients for bariatric surgery should prevent perverse incentives for example patients should not become more eligible for surgery by increasing their body weight. Similarly the selection criteria should not forbid bariatric surgery for patients who have lost weight with non-surgical methods.

Population Needs. 1.1 National/local context and evidence base Obesity and overweight are a global epidemic. The World Health Organisation (WHO) expects expected that approximately 2.3 billion adults worldwide will would be overweight by 2015 and more than 700 million will would be obese. The prevalence of obesity in England is one of the highest in the European Union. In England: Just over a quarter of adults (26% of both men and women aged 16 or over) were classified as obese in 2010 (Body Mass Index (BMI) 30kg/m2 or over). Using both BMI and waist circumference to assess risk of health problems, 22% of men were estimated to be at increased risk; 12% at high risk and 23% at very high risk in 2010. Equivalent figures for women were: 14%, 19% and 25%. There has been a marked increase in the proportion (doubling) that are obese, a proportion that has gradually increased over the period from 13.2% in 1993 to 26.2% in 2010 for men and from 16.4% to 26.1% for women. BMI Definition BMI range (kg/m2) Underweight Under 18.5 Normal 18.5 to less than 25 Overweight 25 to less than 30 Obese 30 to less than 40 Obese I 30 to less than 35 Obese II 35 to less than 40 Morbidly obese/obese III/severe 40 and over Overweight including obese 25 and over Obese including morbidly obese 30 and over Obesity is directly associated with many different illnesses, chief among them insulin resistance, type 2 diabetes, metabolic syndrome, dyslipidaemia, hypertension, left atrial enlargement, left ventricular hypertrophy, gallstones, several types of cancer, gastro-oesophageal reflux disease, non-alcoholic fatty liver disease (NAFLD), degenerative joint disease, obstructive sleep apnoea syndrome, psychological and psychiatric morbidities. It lowers life expectancy by 5 to 20 years. Direct costs of obesity are estimated to be £4.2 billion (Department of Health). As BMI increases the number of obesity-related comorbidities increases. The number of patients with ≥ 3 comorbidities increases from 40% for a BMI of < 40 to more than 50% for BMI 40-49.9 to almost 70% for BMI 50-59.9 and ultimately to 89% for BMI > 59-9. The treatment of obesity should be multi-component. All weight management programmes should include non-surgical assessment of patients, treatments and lifestyle changes such as improved diet, increased physical activity and behavioural interventions. There should be local access to more intensive treatments such as pharmacological treatments, psychological support and specialist weight management programmes. Surgery to aid weight reduction for adults with morbid/severe obesity should be considered (when there is recent and comprehensive evidence that) an individual patient has fully engaged in a structured weight loss programme; and that all appropriate non-invasive measures have been tried continuously and for a sufficient period; but have failed to achieve and maintain a clinically significant weight loss for the patients clinical needs (NICE CG43 recommendations). The patient should in addition have been adequately counselled and prepared for bariatric surgery. This surgery, which is known to achieve significant and sustainable weight reduction within 1-2 years, as well as reductions in co-morbidities and mortality, is commonly known as tier 4 bariatric surgery. The current standard bariatric operations are gastric banding, gastric bypass, sleeve gastrectomy and duodenal switch. These are usually undertaken laparoscopically. Bariatric surgery is the most effective weight-loss therapy and has marked therapeutic effects on patients with Type 2 diabetes. The economic effect of the clinical benefits of bariatric surgery for diabetes patients with BMI 35 kg/m2 has been estimated in patients aged 18-65 years. Surgery costs were fully recovered after 26 months for laparoscopic surgery. The data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI of ≥35 kg/m2. Other groups have been less well studied but bariatric surgery is reported to be cost effective against a wide range of co- morbidities. Bariatric surgery is a treatment for appropriate, selected patients with severe and complex obesity that has not responded to all other non-invasive therapies. Within these patient groups bariatric surgery has also been shown to be a highly cost effective therapy that prevents the development of co-morbidities. Bariatric surgery in the North West services will require that these patients fulfil the criteria within this specification. Selection criteria of patients for bariatric surgery should prevent perverse incentives for example patients should not become more eligible for surgery by increasing their body weight. Similarly the selection criteria should not forbid bariatric surgery for patients who have lost weight with non-surgical methods.