Welcome to this session of the Select Committee on Health and Social Care and its inquiry into food and weight management. We have already done the food bit as best we can and we are intending to publish an interim report on that as soon as possible. This is now the first session in the second half of this inquiry, which is on weight management. Thanks to our witnesses for coming. We have already had a roundtable of lived-experience witnesses who came to Parliament to share their stories about what provision is like, their journeys and what they hope for the future. It was incredibly instructive. I want to thank all those participants who came and so movingly shared their stories, which were genuinely moving. Their battles were very real and very much affected the Committee. They remain in our minds, and we will also be finding different ways of sharing that testimony with everyone in due course. Today we have a series of experts who are going to help us make sense of the landscape as it currently stands. Could they please quickly introduce themselves?

My name is Claudia Coelho, a diabetes and endocrine consultant at Guy’s and St Thomas’. I work in a specialist weight management service covering tiers 3 and 4. I am here today representing the Association for the Study of Obesity.

I am Susan Jebb, a professor of diet and population health at the University of Oxford. I lead a research team that works on the prevention and treatment of obesity. I have been an adviser to the Department of Health and Social Care over many years and Governments and so have been involved in establishing some of the national programmes for weight management.

You also chair the Food Standards Agency. Just to be clear, you are not here with that hat on—just in case anyone looking on says, “I recognise her from somewhere else.”

I report to this Committee as chair of the FSA, but today I am in my Oxford mode.

I am Dr Emily Pegg, the medical director for UK, Ireland and Nordics at Eli Lilly and Co. I was previously a doctor in the NHS but have worked in the pharmaceutical industry for the last 12 years.

We will start by reflecting some of the stories that we heard from those roundtable narratives, particularly around the current landscape. We have weight management services across the NHS starting with primary care and moving through to more specialist services. The Committee had a very strong sense that those are quite patchy and hard to access. The participants generally felt—with some small exceptions who felt they got a good service—that it was very difficult to get the help that they believed they desperately needed. I wanted to reflect that to you but also ask for your reflections on the current landscape for weight management services in the NHS.

First, obesity services have improved hugely over the last 15 years or so. There is a better range of options available, they are more effective and more people are benefiting from them. It is important to recognise the progress that we have made. However, I recognise the experience that you heard from people who have had to battle to get treatment. It is patchy and fragmented. That unfortunately leads to real inequity in who can benefit from the services available. We have an incredibly complex landscape in relation to obesity. It has grown in a piecemeal manner. What we need is a new service framework that delivers better outcomes for patients and better value for money for the NHS, and importantly, makes it a much more equitable provision. That is, after all, what we want our NHS to do.

We are going to come to the hub model that you have written to the Committee about.

I agree with Susan’s perspective. We have an issue with the fact that specialist weight management services are very patchy around the country—we know that only 50% of England has access to specialist services—and then we have an issue with capacity. We are experiencing a significant increase in referrals, which has an impact on waiting times, meaning that we have to tighten referral criteria and sometimes even pause new referrals. As per recent data, there are about 50,000 patients on waiting lists for tier 3. Most importantly, the services are challenging to access, and patients may have to wait a significant amount of time, but then there is also limited access to effective weight management treatment—pharmacotherapy, due to the restrictive criteria in the vast majority of ICBs, but also bariatric surgery. There is a clear under-provision of bariatric surgery. The UK does around 7,000 yearly. France, with a similar population and less obesity prevalence, does 35,000. There is clearly a gap in what we can offer from a treatment perspective.

We would certainly agree that the services are disjointed and fragmented, and they do not reflect the scale of the challenge and the underlying biology of obesity as a disease that requires chronic, ongoing management. Some of the stats we have had access to—part of the challenge is that the actual statistics and data are not so easy to find—show that between 2007 and 2020, only 3% of patients were referred into weight loss services who were eligible. If you look at the data of a sample tier 2 service that we had access to data from, only 35% of those patients referred in actually completed the programme, of whom only 15% achieved at least 5% weight loss. So even once the patient gets access to these services, they may not be achieving the level or sustainability of outcomes that we would hope them to achieve to impact their long-term health.

I was in the doctor’s surgery with my child on Monday and noticed something that we have seen mentioned in a lot of the written evidence, and it is the first port of call for a lot of people: an offer of 12 weeks with one of the Slimming Worlds or Weight Watchers of the world. It was really striking in our roundtables how scathing a lot of users were of that offer. They not only felt that those programmes were not sustainable in the longer term, but someone described them as a cult. They really disliked them very strongly, and that came out in both the panels that we ran. I want to start by questioning the evidence for those interventions. Do they work in the long term for the people who GPs are trying to avoid referring on to tier 3 and tier 4 services? Those interventions might work for others, but we are talking about people living with obesity at this point, rather than just being overweight. Is this the right path for them, or are we just doing something for the sake of looking like we are doing something?

I am really pleased you started there, because I think it is incredibly important to remember that those kinds of programmes are the bedrock of the service that we provide. They are the most cost-effective interventions that we have, and they are being rolled out at scale. The challenge is that those so-called tier 2 services are incredibly varied. Some are commissioned by the local authority. It might be as little as referring people to the local leisure centre for 12 weeks. It might be, as you say, a referral to a community weight loss group, or to one of the so-called digital providers—remote providers—which is mostly a commissioned service. Just after the pandemic, NHS England set up the Digital Weight Management programme in order to provide national access to a 12-week weight loss service. At the moment, it is for people with diabetes and hypertension, but they are looking to expand those criteria. The outcomes for that are good, given the low intensity and the low cost.

When you say “good”, what do you mean?

In the national programme, the mean weight loss is about 2 kg across everybody and about 4 kg for those people who complete the programme in the 12-week period. That is not to be sniffed at, given the very low cost—we are talking about £100 or maybe a couple of hundred. That is really helpful for some people. It is clearly not enough for people with more severe and more complex obesity, but it is an important part of the pathway. There are already something like 125,000 people a year who access that service, and the Government have committed to increase that to 250,000 over the next couple of years. It is not the answer for everybody, but it is an incredibly important part of the overall portfolio. It is not being offered to people who do not have obesity at the moment because, frankly, there are so many people who have greater clinical need.

I was really struck by this. I have lived with obesity and overweight all my life. I have had a bariatric operation. I have been on Orlistat or whatever the more generic name is—forgive me; that is the version I was given. I have tried it all, apart from GLPs because they were just not available at the time when I was really trying to get to grips with this. But 12 weeks, especially if it is your first time encountering this kind of regime, is nothing. From the lived-experience voices, it was really clear that this is a constant thing throughout your whole life. I question whether 12 weeks is enough to learn anything. Is there evidence to show that it has a long-lasting effect?

I will give you a different bit of evidence first, which comes directly from a study that we did probably a decade ago. We compared referring people to one of these programmes for 12 weeks with offering them 12 months of referral. Like you, I instinctively feel that this is a chronic relapsing condition and people are going to need support for longer. What we found was that people who had 12 months’ access lost a bit more weight. In one year they had lost 7 kg, whereas the others in the trial had lost almost 5 kg. However, when we looked at the cost-effectiveness, it was much more cost-effective to have a 12-week programme than a year-long programme. You are essentially talking about four times more cost, but only a small amount more weight loss. This is the conflict that we see in lots of weight—

But what happens after? The lifetime cost is the actual measure of cost-effectiveness, surely.

With every single weight management programme, when it comes to an end, people regain weight. After behavioural programmes, they regain weight a bit more slowly than you might expect. It typically takes people about five years to get back to their baseline weight. Of course, that is not what we want. Nobody goes into these programmes intending to regain weight, but we need to remember that for a very low cost, you get five years-worth of metabolic benefits for these patients. It is not the right answer for everybody. It is not even the best answer for many people, but it is a good answer for part of the NHS service provision.

This will be sad for people who are trying to lose weight, because they want to lose weight once and then stay at their new weight forever. Am I to understand that from the system’s perspective, it is better to lose a bit of weight—a stone, for example—regain it slowly over time and then reintervene? The system, with the way it is set up for value for money, thinks that is a better way to deal with obesity and living with overweight. Have I understood that correctly?

I hope this does not sound flippant, but I do not think the system has thought about it quite that hard. What we have is these programmes, which are effective; we know what they do. One of the problems at the moment, which I am sure we will come on to, is that these services and programmes have been introduced individually. People set them up with good intentions. They organise the digital programme in the best way they can. Then we have the Path to Remission with soups and shakes, and that gets organised in the best way it can. Then we have a GLP programme. What we really need to do now, and what I hope the Committee will encourage us to do, is think about the whole system and how these programmes fit together, and what are the right pathways for people. At the moment, it is organised around services. It is not organised around people and what they need in their journey. As we have said, it is a chronic relapsing condition. It is about facing up to the fact that people are going to need lifelong care, and that there is a huge number of people who can benefit from weight management support. The challenge for the NHS in providing that is extraordinarily huge. We have to plan for the NHS as it is now, rather than the NHS we wish it was. That forces some really hard choices.

We will have one supplementary question, and then I will come to the other panellists.

I will probably ask something similar of the next panel, when my questions are due. Yesterday, the new GP contracts were announced, including £1,000 in support—I will not call it a bonus—for referring people to weight loss programmes and £4,000 for prescription of GLP-1s. Is that learning the right lessons and do you think that it makes sense for the different bonuses to be separated out in that way?

We are certainly supportive of incentives being provided to general practice to give better care to patients living with obesity—incentives are provided for many other conditions, too, of course. There are two QOF indicators: improving diagnosis and recording of BMI; and improved referrals to structured weight management services and the prescribing of medication. That is about £3,000 per GP surgery, or about £25 million overall. We are certainly supportive of incentives being provided to ensure that the right care gets to patients, but we see this very much as a first step. It is not the whole picture because, as Professor Jebb has just outlined, we need to be able to offer a much more holistic service to patients living with obesity. We see that as a good first step.

Previously, under what was called the nationally enhanced service incentive, GPs were paid I think £11.50 for each referral to weight management services. I have not read the detail, but my understanding is that that has now been withdrawn and rolled into this wider provision, which I think is sensible.

We can indeed try to incentivise referrals, but once again, if we have specialist weight management services that are struggling with capacity, we have to increase the capacity in those services, with that access to effective weight loss treatments, before prioritising referrals. My concern is that patients will join a waiting list. We do not yet have in obesity the stratification in other chronic diseases—it is very heterogeneous—but we might have patients with complex and severe obesity who are going to be waiting on waiting lists. We have to be aware of that.

Do you feel that, within that list, it would be better to prioritise people who are the most complex? Is that what you are advocating?

Ultimately, it would be good if some of this funding went towards delivering the service and the treatments, not only to incentivising the referrals.

What I would offer as a counterargument is that at least this allows us to see the scale of need. If we are not encouraging GPs to make the referrals, how do we fully know what the need is? Do you agree or disagree with that?

I would disagree, because then we have thousands of patients on a waiting list, who have a high expectation of a treatment that they will have been waiting a long time for. As you mentioned, an audit the other day showed that when patients are seen in clinic, they have already been trying to lose weight for years and have tried several interventions. They are really looking for treatment, and treatment in a timely manner. Putting them on a waiting list is not the right option.

We will come to other options in a moment. I want to talk briefly about ICBs. We are neatly moving on to the fact that, broadly, this is commissioned locally. We are of course going through a period of reorganisation in the NHS, as ICBs become strategic commissioners. Do ICBs have the specialist knowledge in-house to be able to commission such services effectively?

There has to be a national framework. There have to be minimum requirements for how the services should work. If we do not have those national requirements in place, it will not be a priority for the ICB and we will not have obesity services. That is what is happening currently. In many cases, that is related to a lack of funding so, nationally, ringfenced funding could be important to make sure that ICBs are indeed delivering specialist weight management services.

You would like ringfenced funding. Emily?

When we think of patients living with obesity today, probably similar to some of those people whose experiences you heard, that path is uncertain. It is based on their geography, and they are unlikely to get care at the point and in the time that they need it. We know from work that we have done—a real-world evidence study—that patients are often diagnosed only once they have already been diagnosed with at least one comorbidity as a result of their obesity. The diagnosis is happening later than we think it ideally should be. We believe that we need a centralised and centrally mandated system delivered by ICBs that allows a sustainable way of delivering obesity care over the long term, but the current geographical disparity in what people get offered needs to change.

I completely agree that we need some sort of national framework. In the end, I think it is right that this is managed through the ICBs, but what we see at the moment, and part of the reason why we have such patchy provision, is that ICBs are doing all sorts of different things.

Why are they doing such different things? Is that because they do not have access to the right research? Do they not have the right commissioners? Is there no consensus on what the right things are? Why is it so different in this case?

That is a question for commissioners, but I think it is complicated—we have just been having this discussion. How do you work out whether it is better to give more people the chance to lose just a little bit of weight or give a few people the chance to lose a lot? That is very complex, so different boards will make different decisions on what they think is right for their population. The other point is that this has uncovered that we cannot imagine that we can deal with this entirely through specialist weight management services, and that comes back to needing a portfolio of treatments. We need to remember that with every intervention, some people do remarkably well, but it is incredibly hard to predict at the start who that is going to be. For some people, what we probably need is a pathway—that is not to restrict access to specialist services, because some people definitely need them, but it is at least to manage progress so that we do not jump everybody into Claudia’s waiting list.

What we kept hearing as a result of this was people feeling abandoned; they would try something—they were not obese enough to be able to access the next level of service—but it was clearly having impacts on their mental health, and a life event may have happened that made them go in the wrong direction. I met a family who very tragically lost their mother. After that bereavement, a family member put on a fair amount of weight. That then started to affect her mental health. She could not afford GLP-1s, so she decided she was going to try to find a private practitioner who would give them. That was an illegal practice, and she lost her life as a result of that. It is still with the coroner and going through the court, but the family have spoken publicly about their distress and are potentially the first family that we are aware of who have lost a family member to GLP-1s—it is still unclear exactly what caused that. That is a tragic story, and there are other very similar stories of people who are at such points of despair they are willing to turn to all sorts of places on the internet and elsewhere to find the magic bullet that they are now seeing as GLP-1s. I have a specific question—I do not know whether you can answer it, Emily—on the ability of the state to be able to police the online space for illegal GLP-1s. To what extent do you feel that resources are available to do that? Is what is happening effective? My question for Susan and Claudia—and Emily, if you want to chip in—is: what can we do to help protect people from the worst instances where they feel abandoned, the pathways are not working and they are turning to something that could be very harmful? How can we help to protect them?

We are always incredibly sad when we hear stories of patients trying to access medicines and accessing counterfeit versions of medicines that then cause them harm—we do not like reading those stories. We work very closely with the MHRA and other law enforcement agencies around the world to try to tackle counterfeit sellers of medicines, often through social media and online providers. We are very proactive in doing that. We are trying to actively take down social media sites as and when we become aware of them, and we are working closely with the MHRA if we become aware of counterfeit medicines.

Do you feel that the MHRA has what it needs to help do this?

It has certainly been very proactive in its engagement with us. I am not sure that I have the knowledge to answer whether it has the scale to tackle the full size of the problem.

What else can we do to help protect people when they are falling through these cracks?

I do not think that I can answer that. It is not something that we have done any research on; Claudia probably has a more clinical perspective.

When we see patients in clinic who do not meet the criteria and are considering going private, we always make sure that they try to get it from a reliable source, and we do discuss. So we do provide education to patients on a one-to-one basis about ensuring that they are getting a private prescription from a reliable source.

Finally, one of the key asks of the roundtables—it was quite striking, and it was a much stronger call than I was expecting—was for this country to change the way we define obesity. There is the WHO definition, and other countries define it as a disease; I noted that you used that word earlier, Emily. I heard you say “condition”, Susan, which is the other term. I do not think that the participants really cared, but they felt very strongly that what we are saying at the moment is totally inadequate, because we do not call it either of them. Therefore, it is not treated as the relapsing-remitting condition or disease that it should be. Do you have an opinion on that, Claudia, to complete the set?

ASO’s view is that it is a complex condition. The World Health Organisation has classified it as a disease, as you described, with complex pathophysiology and a relapsing nature because it is associated with significant morbidity and mortality. We believe that the availability of effective weight loss treatments gives a modern understanding of obesity as a treatable and chronic condition. We acknowledge that it being classified as a disease may strengthen the policy case for access to chronic treatment and long-term treatment funding. Regardless of that, I do not think that its being defined as a disease or not should delay any of what we are discussing now, which is accessing specialist weight management services and treatment. Whether it is classified as a disease or not should not change the outcome.

That was where it was leading to. One of the reasons why the roundtable was very keen on that kind of definition was the sense of personal responsibility versus something that has happened to you and that you now need to live with. It might help with a bit of the societal shame; if you see obesity as treatable and not your fault, that would help in the culture shift. That is the much more interactable thing that we are also aiming for, and we heard that it is what they would love to change the most. Clinically—I suppose that this is the other bit of the question—does changing the definition actually change what we measure, such as the outputs, or do we have all that information and this is just a package?

It would not change. The modern understanding of obesity is not only BMI per se, so we take into consideration other measures and weight-related complications—mental, mechanical, and metabolic. We already take that all into consideration.

But we don’t, do we? When you present at primary care, that is not what the GP looks at. The GP measures your BMI, and that is pretty much it.

There is a shift, even towards NICE guidance, and in the teaching and training we are doing, from the BMI into a complication-centric approach. Waist and height ratio is very clear in NICE guidance because it allows for further stratification. As we know, it is correlated with increased cardiovascular disease. Maybe we are not quite there yet in practice, but that is the new understanding of obesity, and that is what we are trying to do in practice.

I see: the research is clear, but we have yet to cascade that fully into services. Have I understood that correctly, Susan?

Yes. I would agree with all that. The other point that I would make—I guess that I am a public health professional at heart—is that moving towards classifying it as a disease risks distracting from the fact that obesity is a completely normal response to the extraordinary world we live in, which we did not evolve to live in. I worry that it distracts attention from the importance of primary prevention.

That is why we started with the food part of this inquiry. We have heard extensive evidence around that already.

As I have already said, we certainly believe that obesity is a disease. When you look at a definition of a disease, we believe that it meets those criteria. However, I would also agree that, even if we cannot agree on whether it is a disease or a condition, the impact of it on patients’ health, and the knock-on implications of the comorbidities that patients living with obesity end up being at risk of, mean that we need to treat it with the same seriousness, regardless of whether we consider it a disease or not. We certainly believe it is a disease. There are underlying biological differences in a patient living with excess weight or obesity compared with someone living with a normal weight. That is a chronic, long-term, relapsing, progressive biology, as the WHO outlines, that needs management in a chronic, long-term way. To go back to a point we talked about earlier, it is not just the proportion of patients who lose some weight that we need to think about with an intervention; it is what proportion of weight they lose. It is well documented in the literature that losing 2% versus losing 15% gives you a very different outcome in terms of the risk of ongoing comorbidities. That extent of weight loss, and the sustainability of that weight loss, is also something we need to consider. Look at the digital health programme: in the data that we have seen, 46% of patients completed that and 15% of those people achieved at least 5% weight loss. I wouldn’t say that that is effective to the extent we want to see or in terms of sustainability. We certainly believe that obesity is a disease, and the process and system by which we manage it as a disease needs to reflect that.

To underline this point, do you think the Government should make a decision about that terminology? Do you feel that they should be doing that, or is this something that the sector needs to come to first?

We believe it would be beneficial for it to be seen as a disease, as, for example, cardiovascular disease or type 2 diabetes are seen as diseases.

Is that in policy terms? I think we are just talking about how we shift the levers of policy, currently.

The important part is that it is treated in a centrally mandated and systematic way.

That is clear.

That would be the priority, from my perspective.

I honestly do not think it would make a blind bit of difference.

I agree. I think it is not a priority.

It is not a priority. Thank you very much.

Susan, in some of your earlier discussions you talked about taking a whole-systems approach rather than a programmatic approach to delivery. Has one of the challenges in moving to such a model been that, ultimately, we need evidence-based interventions, and it is easier to test an intervention than a system approach? You talked about the diabetes remission programme and the diabetes prevention programme; they were quite evidence-based interventions and were heavily tested. How would you develop such a robust, evidence-based model on a whole-systems approach intervention or on a menu-based approach?

It is really hard. Researchers like me love doing trials where you compare A against B, and you come out with an answer at the end and then we can all go home. As we said, you need to think about obesity in a much wider context. It is about trying to match the right treatment with this patient at the right time. One of the things that really concerns me is if patients enter a service—let’s imagine you have a patient newly diagnosed with type 2 diabetes—and they go into the Path to Remission programme. Soups and shakes are quite tough, so they find that this is just not for them. They cannot hack it. What happens then? They just fall out of the service. It is like going down the ladder and back to square one. We need something that picks them up and says, “Okay, we got this wrong; this is not the right treatment for you, but we have other treatments that we know are effective.”

Is this the hub model you talked about?

We need somebody who stays with that patient as their kind of coach or buddy and helps them find the right service for them.

Like a key worker or navigator of the system?

Yes. If you did that, it would be easier to identify those patients who, at the beginning, should not be catapulted into specialist weight management services, but perhaps haven’t really tried to manage their weight before and could benefit from one of these lower-level programmes.

Those programmes are tested in certain patient groups, such as the Diabetes Prevention programme to prevent diabetes, and the Path to Remission programme for people who are diagnosed with diabetes to put them into remission, and there is evidence of that. Is there a risk that more fluid movement between models of different potential patient populations would undermine the evidence base for those programmes?

I think we have just got to be realistic here. They work by weight loss. Weight loss is the mechanism of action; it is the common pathway by which you then deliver these different clinical benefits. If we focus on that, we can navigate patients between different services. The system needs to organise that. At the minute, if you ask GPs, they will say it is so complicated because every programme has a different piece of paper and different criteria. There is so much friction. That is part of what puts them off doing it. We would like to see people being referred to a specialist service that then knows everything available in that area and can actually point people in the right direction.

A specialist weight management hub.

Yes. It can then move them between services if one is not working for them and, crucially, collect data. That is really important. One of the problems with a lot of the work going on within the NHS, as opposed to in some of the private providers, is that we have really poor data about who is being treated, how long they stay in the service, how much weight they lose and what happens to their health. If we brought that together, we could start building a really solid data infrastructure that would then allow us to do that long term. What happens in the long term? Realistically, people are not going to stay in the service forever, but we want to be able to link up to their electronic health records so that we learn what is working as we go. I think what we need is real-world evaluation, rather than trials. You need a service with a very solid data package around it.

That is really clear, thank you. Is there a risk of bypassing GPs, as they are currently the gatekeepers to the system? As I think you mentioned, obviously these individuals often have to have multimorbidity to get on to these programmes; it is not just obesity that they are facing. They are potentially facing diabetes and other conditions such as MSK and so on. Is there a risk that the ideal hub model might suddenly fantastically deal with their weight-based issues, but they might not get access to the other support and treatment that they might need for other physical and mental health conditions?

It should not mean that at all because you are not taking patients away from their doctors. The doctor is just referring them to another service and, in an ideal world, that data is going back into their electronic healthcare record. Patients will still be seeing their GPs for their medical care. This is just about helping people to access services. It starts to address some of the comments that you heard from the patients that you met about feeling unsupported and feeling like there was nobody that they could turn to and being left on their own to work out what is available and what they are eligible for.

On the hub model, you talked about one of the challenges of testing as being the ICB-based commissioning model of local need. You touched on that a bit in today’s session. That is a complete departure, I suppose, from the rationale of commissioning care locally. Why should this, and not any other aspect of care, be commissioned at a regional or national level in hubs? Presumably, you could make the case for it in other areas of care.

You probably could. It is a different way of doing it. It is the effort in my research team. It is where our thinking has led us—to what would actually be worth trying now. There may be an opportunity for that to happen. New funding, which is being provided by Lilly and UKRI, is setting up OPIP, the Obesity Pathway Innovation programme. That is really encouraging ICBs to bid for money and think about how they are going to run their services. I really hope that we see some genuine innovation in the way services are delivered. Of course, I would be delighted if people took up the idea of a hub-type model.

Let me turn to the role of digital service delivery, which some of the panellists have already touched on—Emily, I think you touched on it in the evidence you gave about some of the evidence of weight loss. To what extent is that desirable in and of itself or is it a way of dealing with backlogs or resource shortages? Is it a second-tier option in terms of quality? Or is there parity of quality between digital and face-to-face support interventions?

Our perspective is that digital offerings absolutely need to be part of the package if we are going to get care to all patients in a way that is sustainable for the healthcare system. We appreciate and understand that not all patients are going to be able to access direct care through their GP. It absolutely needs to be a holistic package, of which digital may be a part. I am glad that Professor Jebb mentioned OPIP; we are really hoping that it will inspire some innovative thinking about how we can run services in different and more innovative ways that allow patients access and to essentially lose weight over the long term in a sustainable and supported way.

Does anyone else on the panel want to talk? Susan, you wanted to come in.

It is important to first define what we mean by digital services. Often when people say digital what they mean is remote. They mean you talk to somebody on the telephone, rather than seeing them face to face. That is quite basic digital. That is one bit, and for many patients that is a good option. They do not want to traipse to the doctor or whoever else. But it goes right through to people who are having things through apps. That is a kind of WhatsApp-type delivery service. Again, that is a variant on what is being provided face to face. The newer generation of digital, which we are beginning to see come into the market, is genuinely more creative. It might involve integrating data from wearable technologies. It might provide just-in-time prompts to people at the moment when they are most susceptible to impulse eating and so on. We are beginning to see more creative digital technologies. Digital, of course, can support some of the other provisions. Some of the weight loss medication services are being provided remotely and are often described as digital. It is important that we are clear what we mean by digital because, in many ways, everything other than going to see your doctor or a healthcare professional in person is described in that way.

From an equity perspective, we do need to think about whether digital meets the needs of everyone in society. We certainly know from some of the ratings of the Digital Weight Management app currently provided that minority ethnic groups are much less likely to rate it as useful, or to agree that the programme had helped them lose weight. We need to have a suite of offerings that meet the needs of the individual patient, bearing in mind where they are on their obesity journey, but also their background and the way they need to access services.

You said that is a complex picture that varies from area to area in terms of what services may or may not be available or commissioned by the NHS, local authorities and, potentially, voluntary sector provision. Is there a role for digital in ensuring that clinicians and patients understand better what is available in the complex service landscape? Is there any evidence about improving accessibility just by having digital-based access, rather than traditional referral pathways or self-referral through digital?

I am not aware of data related to that question.

Self-referral is a bad idea in general because it increases inequality in the system. We get much more equitable outcomes when you have referral through healthcare routes than when people self-refer.

Do you not see private prescriptions as self-referral by another means? We know most people who are using injectable treatments are self-referring themselves to private provision. That is happening anyway, so would it better if self-referral or self-supported access was happening through an NHS supported platform rather than a private pharmacy platform?

If people are paying for it privately, you pay your money and you take your choice. I am concerned about what happens in the NHS. What the NHS does is ensure that it is providing its services.

But you would potentially get no wraparound support? If I went to Pharmacy4U or something and ordered an injectable, I would not necessarily get any contact from my GP, a health professional or a health hub. But if I went on an app, felt I needed something and referred myself to a programme, or share my interest in it, would that not potentially be a more supported approach to weight management?

It would be a more supported approach and better for that patient, but it gives them preferential access into the NHS. We have talked about how resource constrained we are. I would like to see that the private provision of weight loss medication has to come with wraparound care. We need to make patients understand the benefits of that. In our recent systematic review, we showed that behavioural support alongside medication increased the amount of weight people lost by about 4.5 kg. That is a real benefit for patients, so I think people need to understand that, and we have to encourage them.

That is helpful.

Can I just add something about self-referral? We wonder whether we should be doing it the other way around, so should we be case-finding in the community? We now have access to very good primary care databases that allow us to understand the BMIs and the complications that the patients may have, and we know that inequality is a huge issue in obesity. Should we not be a bit more proactive and not expect the patient to go to the GP to ask for a referral, and then the GP to do that referral? We are doing it in south-east London with the tirzepatide roll-out, and I think it could be an option to ensure that we are getting equitable access to everyone who meets the criteria.

Where you do believe that would sit in the system best, in terms of outreach and proactive engagement?

It is based in the ICB that has access to all the data and then runs the clinical codes. As you can imagine, it is not straightforward, because many times cardiovascular disease is coded in many different ways. It is really about trying to use the excellent database that we have, and trying to do it a little bit the other way around, with us proactively reaching out to patients.

Is that via primary care, secondary care or local authority public health?

It is primary care, with GP federations.

How do you deal with the capacity issues that you touched on earlier as being the priority, as opposed to incentivising referrals. We know that there are capacity issues to get people into services. If you are proactively going out and finding people, and we are already struggling as a system to deal with the people who are presenting to the GP and asking for that, how do you manage those capacity challenges?

I completely agree that it is a significant challenge, because you cannot stop the GP referrals that are coming from patients who went to primary care. However, it allows us to do what I initially mentioned: ensuring that specialist rate management services are assessing, treating and managing patients with the complex and severe obesity that we see in the cohort with the highest needs.

So you are actively finding the most in need.

Exactly.

We touched before on GP-based payments. Following on from that point, Claudia, do you think the payment system needs to have a more graduated focus that heavily incentivises the most in need, rather than a blanket payment approach for referrals? Do we need a smarter payment system that looks at outcomes as well as referrals, such as a genuinely outcomes-based system that looks at uptake and completion of courses? Would that help at all, or is it just about capacity?

I think that makes sense that, instead of having a blanket approach, you try to be more specific and prioritise the patients with highest needs. Obesity is highly prevalent, and we somehow have to try to prioritise and understand which patients face the highest risks, and where these medications and treatments will add more value. We do not quite understand that yet.

We need to be careful not to muddle two things here. The incentives we were talking about earlier are to encourage practices to make appropriate referrals into services. What you are talking about is outcome-based commissioning, which is where we want to ensure that the services are delivering the outcomes that we want. That is not on the GP but on the service that they are being referred to.

I guess that QOF does different things, though. For example, in the diabetes world, you can refer someone to book a diabetes education course, and there is a QOF for that. I guess that QOF was changed to attendance at a course to encourage a good referral and actively ensure that the GP service played a role in making sure that people actually attend the course, rather than just being told about it some way through a letter.

I totally agree with that, but you can only—

I am not necessarily mandating either one. I am just asking whether you believe a referral-based payment system is the right approach. Whether it is a primary care-based incentive, a provider incentive or an incentive for the ICB, do you think that a more outcomes-focused incentive approach is a better way of using the finite money there is?

I definitely think that it should be about effective referrals, so that the referral gets taken up. I think the separate issue is that, when we are commissioning services, we need to move towards rewarding services for delivering the outcomes we want—or delivering patients who complete the programme. NHS England is already doing that: with the Digital Weight Management programme, for example, although the drop-out rate is quite high—as Emily has said—the NHS pays only for patients who complete the programme. I think we have to get the financial structures optimised if we are going to get the best results.

We would certainly agree that, when services are set up, we should have data not only to demonstrate how the patients are performing in the service—how much weight they are actually losing—but to ensure that that is an extent that is likely to impact their outcomes and is sustainable over time. I completely agree that we should be looking at the outcomes of these services, and holding services to account if they are not achieving those.

Should the NHS take the same approach to pharmaceutical interventions as well? Obviously the NHS is contracting Lilly and others around injectables. Rather than a simple price-based approach, should there be an outcomes-focused approach? I think Susan talked about the requirement that the private sector develop wraparound support. Should the payments someone receives for the medication that is prescribed be conditional on the uptake of that wraparound support? What are your thoughts about that?

We probably need to separate private provision from NHS provision, but certainly all providers, wherever they are prescribing a medicine, should be doing so in line with the licence criteria for that medicine. For weight loss medications, those do include an element of what would be considered to fall into wraparound support—lifestyle and dietary intervention. I guess that is a slight aside. We are very open, across the world, to discussing more innovative potential models for how payments can be made. We are certainly looking to try to achieve the best outcomes for patients who go on to our medicines.

In the programmes that the NHS is commissioning nationally, I think we have good data on what works. I think it has done a really good job in monitoring and evaluating services and decommissioning those that do not work. The data is much less good where it is scattered around the NHS in different services—maybe Claudia can comment on the challenges of doing that. I think it comes down to having different services with different referrals. It is a very complicated landscape, but it should not beyond the wit of man.

There are three different sets of data. There are clinical trials, where we absolutely know what happens in the trial. In the last five or so years, we have been able to link those patients who take part in the trial to their electronic healthcare records, so we are now able to follow what happens to people in those trials in the long term. That data is beginning to accumulate. The people who take part in trials are a subset of the population—they are not the general. All the NHS England programmes that they have been set up have good data monitoring and evaluation. Again, those are mostly focused within the programme, but people now are linked to their long-term health records, so we can follow them up. Those are the ones that I know about. They are getting better all the time. However, it is harder in the case of people being routinely referred by their GP to the local leisure centre or to a one-off course of weight management. Now, that will be coded in the electronic record, so we are beginning to look at exploring things like the OpenSAFELY database. You might have seen that this was used during covid to monitor the roll-out of the covid vaccines. It collects all the data that is available in electronic healthcare records, so we could use that to look at patterns of referrals and then, in time, to follow those patients up in the long term.

I completely agree—the data is completely inadequate. We do not have a lot of data, and it is really important that we structure this. It is important that we track the initial baseline demographics and the ongoing long-term outcomes of patients who are on interventions. It is also important, from an inequality point of view, to understand who is accessing the services and how patients do from an outcome perspective—exactly what you described. It is about trying to understand better what works and what does not work. Currently, there is a national obesity database, but the information that it provides is very limited. It has not been particularly useful. The diabetes database, on the other hand, is a very good example of how we can, in a systematic way, get data from primary care and secondary care that allows us to benchmark and ensure accountability.

I think it is a start. We have to make sure that the data is mandated. It has to be mandatory for specialist weight management services to fill in the data or be able to retrieve the data somehow. I would also advocate that we do need that infrastructure, which currently we do not have in place.

When we think about a database, I do not believe that that needs to be focused solely on treatment, because a patient is going to live with obesity over the course of, often, much of their life. They will go into different interventions at different points. It may be lifestyle interventions, initially. They may then enter treatment and end up having surgery.

We know that it is a chronic, relapsing and progressive disease that patients, as I think you have heard, live with over the long term. They often talk about the fact that they have relapses. They lose weight and regain it, and that is very consistent with what we understand in the literature of the biology of obesity. There is an underlying biological reason why that happens. I believe that data collection needs to be over the course of a patient’s life. We would not, for example, take data for a diabetes patient only at the point at which they take insulin; we would take it over the whole course of their disease.

I am talking about type 2, in my mind, but for any other chronic disease, we would not take data from one little portion of when they have that disease, which they may live with for 50 years. We would advocate for the same holistic data collection, and then holding services to account in terms of how much they can make progress in the outcomes for those patients.

Thank you all very much for coming. I would like to understand weight regain a little better. If people cannot actually keep the weight off, it is just a licence to print money for pharmaceutical companies. Professor Jebb, the Committee had some evidence from NICE in August that suggested that weight regain occurs after two years, but more recent research that you have been part of suggests that it is even less than that. What impact could these findings have on NICE’s assessment of the cost effectiveness of the treatment? Do you think NICE should be looking at its assessment again?

We published some data that was from a systematic review of clinical trials, where people had had weight loss medication. Data was also provided on what had happened after they had stopped taking that medication. We found that typically, on these newer GLP agents, people lost about 15 kilos and, within one year of stopping treatment, they had regained 10 kilos. That was on average, and there is a lot of heterogeneity. When NICE did its original cost-effectiveness calculations, it estimated that regain would occur over, I think, a three-year period. Clearly, if weight regain happens faster than that, you would expect the cardiometabolic benefits to be lost more quickly. That will have an impact on the cost-effectiveness. I think NICE did a very good job, but as the data evolves, we perhaps need to learn from that.

Would you say that it should be looking at reassessing the work that it has already done, because there is now more data out there?

Potentially.

When you say “potentially”—?

I say “potentially” because what we also have to remember is that what happens in clinical trials may not be what happens in real life. Because the way these drugs are being used is somewhat different from the trials, people may continue on them for longer. Again, that will change the cost-effectiveness. If you lose weight and keep it off but you do so by continuing medication, that is a very different scenario. What we need NICE or others—it does not have to be NICE—to look at is a slightly more granular calculation, where we look at the type of patients, because the more severe and the more complicated your obesity is, the more you have to gain compared with somebody who has less complex needs, depending on how long you stay on that treatment. We need to understand better which treatments this is most cost-effective for. We then need to compare it with other options. Although NICE does it in a binary way—“Is it cost-effective or not? Is it below the 20,000 QALY threshold?”—we are comparing these drugs with other treatments for obesity, such as the Path to Remission, where the cost per QALY is very much lower.

That is very helpful. Given the speed at which these drugs are being adopted and given that we are learning all the time about what they are doing, what impact they are having and what impact they are not having over the long term, is there a case for NICE to assess and reassess the drugs and the advice it gives to Government more regularly than it is doing, starting by having another look now? I would be interested to hear everyone’s views on that.

Potentially—

When you say “potentially”, that suggests that you see upsides and downsides. What are the downsides?

Well, NICE has a lot of things to do. We have to ask, “Will their new calculations change what happens in practice?” They may not. What NHS England has already done is say, “Actually, we are going to prioritise patients with the most severe and complex obesity for access to these medicines, and they are the ones for whom it is for sure going to be much the most cost-effective.” The NHS has already interpreted it in quite an intelligent way. I am a scientist. I would love more data—let’s analyse everything more often—but I think we have to ask, “Will it actually change practice?” At the moment, we have a good understanding of where the cost-effectiveness sits, and we need to compare it with that of other treatments. It will change over time as the cost comes down, of course.

It would be good to get the views of Dr Pegg and Dr Coelho as well.

Weight regain in itself is not a surprise to us, and I do not think it should be a surprise to anyone else. If you understand the underlying biology of obesity, which we believe is a disease, weight regain reflects that underlying biology rather than a failure of the treatment that you have withdrawn. Claudia can probably speak more about the clinical picture, but we would never expect, with a disease like hypertension, that if we removed the medicine a patient’s blood pressure would remain low. We would never expect, with high cholesterol, that if you removed the statin, the patient’s cholesterol would remain low. There are some diseases where we have a disease-modifying therapy, like a gene therapy that you give once and do not need to give again, but most medicines fall into the category that these medicines fall into, whereby if you stop them, it is likely that the underlying biology will take over again and the symptoms will return. These medicines have been determined to be cost-effective with a robust analysis. Some medicines have had a stopping rule introduced; some have not. There have been lots of considerations, not just about the cost of the medicine but about the associated costs. For example, how many GP appointments does that patient need, or how many visits to a dietician? That assessment has been robust. In itself, as I say, we are not surprised that if you take away the medication—

When you say that the assessment has been robust, that suggests that it is using the best available data and a whole range of other factors. However, the recentness of the analysis is important. If things are changing all the time, how robust is the data?

Obviously, the assessment is done at that time with all the data that is available at the time of that assessment.

Thank you very much. Dr Coelho, do you have any views on this?

From a clinical perspective, we have the expectation that these drugs should be used long-term. Who knows if there will be clinical strategies in future—when some of these drugs come off patent, when they become more affordable and when we have the orals—where we do combinations of treatments? We have to understand that this is evolving and change is always happening. There may be clinical possibilities in future to ensure that the patients remain on the drug long-term in a cost-effective manner.

At this stage, do you think that NICE should look again at the assessment it has already made?

I agree with Professor Jebb, the expert, that if new data is available it should be reviewed, but we should take into consideration that it should not be reviewed without a change in the management.

Can I ask a couple of questions about other aspects? We have an obesogenic environment, which I know Professor Jebb has done a lot of work on. The Committee has talked a lot about trying to reduce the obesogenic environment through healthy food and so on. Does getting the easy pharma jab not reduce the urgency of tackling the obesogenic food environment? If you can get the jabs, why would we carry on trying to get people to eat more healthily and so on? It is a bit of devil’s advocate question.

Not at all. Nobody wants to be on medication for life. Everybody who is struggling with their weight hopes that their children and their family and friends will not have the same trouble.

I must stop you there. What makes you say that nobody wants to be on medication for life? People who have high blood pressure take high blood pressure pills for life.

They do not want to.

There are all sorts of other conditions that people take medication for. It is a bit boring, but—

The patients that I talk to tell me that they want to come off their medication. People with diabetes want to lose weight so that they can come off their medication. One of the things they have been saying is, “Do I really want to swap one medication for another?” I think that there are very few people who would argue that primary prevention should not continue to be something that we all put effort into as the only sustainable solution. But right now, there are masses of people who really need treatment and support to lose weight.

We completely agree that primary prevention should always be our first line of defence. As Professor Jebb says, that is hopefully to protect the younger generations now from developing obesity. The food environment is clearly an important factor there. But for the 30% of adult patients who are living with obesity—the figure is set to grow to 36% by 2040 and to overtake the number of patients living with a normal weight—there is a need to take action right now.

I understand that, and we have discussed that quite extensively. You say that prevention should always be the first line of defence. Your share price is rocketing. I wish we all had shares in Lilly; we would all be a lot richer. Do you not have a financial interest against prevention? I am not talking about morals; I am simply talking about the money. The more that people do not put on weight and do not live with obesity, the less good it is for you financially, because the drugs that people are taking are causing your share price to bounce up and up.

Our aim as a medicines company is to make medicines for diseases that represent a high unmet need, either where there are not medicines available or where the options for patients are not available. We certainly hope that the epidemic of obesity will not continue to be such a great problem, but we want to help patients living with it now with a treatment option that improves their outcomes and their health outcomes.

But do you not think that—ironically, seeing as people do not seem to keep the weight off for an extended period at the moment—the drugs over the long term could increase obesity in the general population by reducing people’s motivation to tackle the root causes?

This is where a holistic approach to obesity management needs to come into play. All these medicines can be prescribed only if there has been a significant discussion about lifestyle, diet and exercise. We should absolutely ensure, with any medicine, that we have the appropriate wraparound care for those patients.

Do you think there is an argument—Professor Jebb touched on this with my colleagues a minute ago—for it to be made compulsory for people selling these weight loss drugs to also offer wraparound weight loss management to help people when they come off the drugs? Is that something that should be required by law?

We are very supportive of the fact that all medicines should be prescribed and given to patients within the criteria that are set for them by the MHRA when they get a licence. Those do include consideration of lifestyle, diet and exercise.

But would you actually make it a requirement? Would it not undermine your financial interests if it were a requirement? The longer that people maintain the weight loss after having used one of your very effective drugs, the less good it is for you, financially, in the long term. So would you oppose or be in favour of requiring drug companies also to offer weight management programmes around the sales of the drug?

We would like patients to have that holistic package of care, which includes wraparound care and lifestyle management. We see that as critical.

But should it be compulsory that you offer that?

It is already required as part of the licensing wording for the medicines.

I am talking about if you buy it privately online. Forgive me; I was not clear.

We are the manufacturer of the medicine. We do not directly control or have responsibility for the people who are selling the medicine as private—say online—pharmacy providers.

You might have a view, though.

Certainly. Last year, some guidance was issued about the type of service that these online pharmacies should provide when providing access to weight loss medications, and we are completely supportive of that.

Thank you. Professor Jebb, would you like to expand on your suggestion a minute ago? When you sell the drugs, should you be required to offer wraparound care, or at least indicate where people can get wraparound care, and an idea of the costs?

Absolutely. As Emily has said, that is part of the way these medications are licensed for use—with supportive care.

If you buy them privately, I mean.

It is still in the licence, so I think that is for the MHRA to act on.

So if companies are selling drugs privately and are not offering people wraparound care, are they breaking the law?

That is just not my area of expertise.

If they are not adhering to the licence, that is—

So the MHRA should be going on the internet, looking at who is selling the drugs, identifying where they are not offering wraparound care, and stopping them?

At the moment, guidance has been issued. I do not know, legally, where the responsibilities lie in terms of private providers.

The other point is that the quality is really important. There are ways of providing things that are not going to be very effective, and there are ways that are extremely helpful. It is a very complex area; it is certainly outwith my expertise.

I can trail the fact that this Committee is not done talking about these jabs and what needs to happen with them. I want to circle back to a point that was made a number of times and is probably worth underlining. There is very much a conversation—in the public, whenever I do media on this, and indeed from voices in Parliament—about the personal responsibility versus the biology underlying obesity. On a scale of personal responsibility versus biology, where would obesity sit? What does the current research show to inform our understanding of how obesity works? I am not totally sure that Parliament, or wider society, actually fully understands this. I think, Emily, you said, “We all know.” Maybe clinicians all know, but I am not totally convinced that Parliament or the public know. I will ask Emily to answer, because it was your comment.

Claudia may want to come in on this as well, but our understanding of the literature is that patients who have lived with overweight or obesity for a period of time have a different underlying biology from patients who have lived with a normal weight.

But is that different from a genetic factor that might have led to this?

There may be genetic factors, but—

So they have become obese—they have been living with overweight or with obesity—and that itself has changed the underlying biology?

They have a disorder in normal homeostasis—how you maintain normal functions within your body. That is different in patients living with obesity. There is an element of personal accountability and responsibility in many conditions, but that would not stop us treating a patient if they presented. For a patient with diabetes, the mainstay of initial intervention for type 2 diabetes is lifestyle and diet. If that patient then presents with an HbA1c above the level for treatment, we would not refuse to give them metformin—or, subsequently, insulin—just because they did not follow, or were not successful in following, the GP’s advice about lifestyle. We do this already with other long-term conditions and diseases. We would argue that this should be no different.

To be clear about that, once you have developed that underlying biology, is it something that you cannot get rid of and that you have for life?

I think it is. If you want evidence that there is a biological basis, the GLP medications give that to you. These are people who have struggled with their weight. People do not just launch into this; they have tried and been unable to manage their weight without that support. You boost up the hormone that helps people to feel fuller and their weight comes off very successfully because they eat less. The moment you stop the drug, appetite returns and weight rebounds. That really shows that this is fundamentally a biological phenomenon. Clearly, people can exert extraordinary levels of conscious control to override those biological signals, but I think we have to understand how very, very hard it is. It is much harder for some people than for others—and much harder for everybody in a world in which we are surrounded by food and it is heavily promoted. The food environment makes it difficult for all of us, but especially for people who have that underlying susceptibility.

Claudia, I know that this is very much your bag, but please just underline for us and for the public: what has changed in the underlying biology? Why can it not be reversed? Some people get back to a normal BMI and a normal weight and, hooray, they feel it should be forever, but we met some participants in our roundtable who told us about how despondent they felt when they started to regain weight. What is happening in their body that means that that is going to be a lifelong battle?

When I see patients in clinic, it is very important that we understand the underlying cause of weight gain in the first place. Was it related to disordered eating? Is this someone who was previously very active and then became inactive, who works shifts, who is on medication that promotes weight gain or who has severe mental illness? It is important that we try to understand and address, where possible, the underlying causes that are driving the obesity. That is essential in what we do when we see patients with obesity. I agree with Professor Jebb that the medications reinforce the modern understanding of obesity as a chronic disease—that you can lose the weight, but when you stop you regain the weight.

Some of the causes that you mentioned are environmental, but what we are hearing now is that there is a biological basis. You can retake a more active lifestyle, but my question is: has the individual’s underlying biology also changed as a result of living with obesity for a period, or is it that they just have to keep up that higher level of activity? I am trying to understand where this fits. Did something fundamentally change in the cells in the body, or is it about lifestyle choices, which some people say are closer to the personal responsibility argument?

There is the set point theory where, even if you lose a significant amount of weight, the biology in your body—the hormones that control your appetite—will want you to go back to that previous highest weight and will drive increased food intake and weight regain.

And is that a well-understood theory?

Yes.

Thank you very much. It was quite important to go back about 10 steps so that we could fully understand that. We appreciate your time, panel one. Witnesses: Dr Kath McCullough and Dr Munro Stewart.

Welcome, panel two. We really appreciate you coming today. We will start, as we did with panel one, by asking you to introduce yourselves and what you do.

Hello, I am Kath McCullough. I am a consultant in diabetes and endocrinology with a specialist interest in bariatric medicine. I am based at the Royal Surrey in Guildford and am here in my capacity as the obesity adviser at the Royal College of Physicians.

I am a five-session GP partner and the vice-chair of the Royal College of General Practitioners for policy.

Dr McCullough, your evidence talked about better incentivising “clinician and patient participation” and moving to a “twin approach”. Could you tell us a bit more about that and what that support looks like in practice?

Maybe I will start with the twin approach. What has been clearly demonstrated by the previous panel and what you have heard from patients living with obesity is that the current weight management services that are in existence—the tiered service—are not really working as effectively as they should be. What we are proposing is essentially a two-tier service where the vast majority of weight management is done in the community and by primary care colleagues, much akin to the way that diabetes is managed, and that is to reflect the scale and the number of adults living with overweight and obesity. We would then reserve the complex cases and those requiring bariatric surgery, who should be seen in the specialist services. That is what we mean by the two-tier service we are advocating. In relation to incentivisation, we welcome the announcement yesterday about the QOF. As alluded to before, it is a first step. The question is then, what do you do with that? Recognition of people living with obesity in primary care and community settings in the first place is really vital, as is better data collection, and this is one way that that can be done. Then the question is, what do you do with that? What is really important is that at a local level, utilising things like community hubs, you have a directory of services so that the key people who are seeing these patients know exactly where to refer to and you have a suite of options available.

Does it concern you that the vast majority of GLP-1s are pharmacy-prescribed, often online?

There is obviously a concern about the uptake within the private sector. We are hoping that the number of people utilising these drugs within the NHS will increase. I know there is a lot of pressure to be going further and faster with these injectables—I am totally aware of that—but let us just take a step back. If you look at OpenPrescribing data, in November, 263,000 prescriptions of Mounjaro alone were issued at a cost to the NHS of £60 million. That is a huge amount of money. We know that these GLP-1s are very, very effective in various conditions, such as type 2 diabetes, and they are being rolled out. New NICE guidance was published just two weeks ago to try to increase the number of patients accessing GLP-1s for type 2 diabetes. There is also more guidance coming out in May on the use of Wegovy in cardiovascular disease, so we will be seeing more patients on this class of drugs through the NHS.

We are talking about wraparound care, but if 90% of the prescriptions are happening outside the NHS system, as some evidence suggests, we are almost having a parallel conversation to the one that the public are having.

Yes. We know that about 2 million people are accessing these drugs privately. There is a concern in terms of where they are obtaining these drugs from, whether they are from reputable sources, and things like storage chains. You rightly point to the wraparound care or, in some cases, lack of. The WHO issued a warning a couple of years ago about fake medicines, which we know is occurring as well. So yes, there is a concern—there is a risk to patients—and it is really important that there is some form of regulation and that it is overseen.

You spoke about having a specialist in each hub, and we have heard that there is a need for that twin-track approach. How would that be properly delivered and what do you see it looking like? Is it about having a specialist in each community hub? Is it social prescribing? How do you see that twin-track approach being delivered?

There are already some really good models of care available. Women’s hubs are working very well; Lesley Regan has really championed them. It is about utilising hubs within neighbourhood communities. That is not just for obesity or women’s health—things like smoking, cardiovascular disease and cardiometabolic diseases can all be done in the community within these hubs. But it is really important that however this is done, it is done in a way that is holistic, patient-centred and within a multidisciplinary team meeting. We have spoken before and heard from the previous panel about people working in silos within weight management services. That is the case, sadly, in a lot of places. We need to work a lot better between primary care, community and secondary care providers. That MDT meeting could be done virtually. There are digital ways of delivering care as well; you talked about social prescribing. We need to work much better based in the community—as per the 10-year health plan’s shift—moving out of hospitals into community care where patients are and having much better and more equitable access.

This Committee has done a hearing on exactly that point, and I would refer people who are looking at the issue to that session.

Speaking of multidisciplinary teams, I am going to bring in the GP, Dr Stewart. Dr McCullough talked about smoking cessation and other things where multidisciplinary teams are working well. Drawing on the sort of things that you have seen in GP practices, are there good examples of how we could make the wraparound care around obesity work better—looking at obesity examples, but also looking at other examples in healthcare that you have seen, around things like smoking and so on?

Yes. I would give the context of a GP service that is trusted by patients. Patients do trust us and we do have an impact when we give lifestyle advice. When we give treatment for obesity or whatever it is, it is effective. We can do that, but the context would be that we now have 16% more patients per GP than we did in 2015, so we are a service that is beyond capacity. We are already seeing quite an increase in workload from weight loss medications: one in 25 consultations now is about or mentions Mounjaro. The funding package, which will be for the BMA to negotiate, does not cover the fact that we have already had a big increase in our workload, but of course, yes, we want to help patients. GPs want to—

Can I pause you there? That is a really interesting statistic. Is it because people simply weren’t presenting with obesity symptoms before?

It is because there is a demand for these drugs. There are people seeking these drugs privately, then they are coming to us. Most days I will have a letter from a private prescriber saying, “We’ve given this drug to your patient.” Then we need to check the record and we need to add it to the record. So there is a workload implication already there.

But do you think that people just weren’t seeing obesity as a medicalised problem before, so now you are getting more people presenting for that reason?

Yes, we are seeing more of that; I think that’s fair to say.

In some ways—without wishing to put words in your mouth—it is not necessarily a bad thing that more people are coming to doctors and saying that they want to get hold of their weight management. It’s just that there is a bit of a trend forcing them down a particular route. Would that be fair to say or am I putting words in your mouth?

We want to treat patients. We want to help them with obesity. We want to improve health. It is good if we are able to do that.

Yes, and people are seeing it more as a health condition, which may well be a positive.

Yes—there is a good side and bad side to thinking of this as a condition. I was listening to the previous panel with interest because I think there is a danger of over-medicalising it as well. I think we can all see from the discussion we have had so far about the genetic predisposition, the environmental triggers, the change in the metabolism with obesity and the lifelong nature of this, that if we try to completely medicalise it, there could be an extremely high cost to the NHS workload. We have to put all this in the context that prevention is better than cure and that the biggest impact—I know it has been discussed elsewhere, but we also have to comment on it—that the Government can have is by changing the structural and economic drivers that lead to obesity.

The food system?

The food system, but not just the food system. I would defer here to the Obesity Health Alliance, who have a range of policy suggestions. We are talking about the exercise environment, poverty, housing, food availability, the food system—there are a number of factors here.

What you are saying about the role of GPs is very interesting. Being a GP is pretty challenging at the best of times, and you are being asked to do more things. We have heard, in the evidence we have received, that weight management systems can be resource intensive, clinically intensive. Do you recognise that description?

Yes.

What is it about the services that makes them so intensive?

Obesity is a complex condition. We need to be providing holistic care, and this takes time. We would estimate half an hour for an initial assessment. If you are prescribing these drugs, there will be perhaps four 15-minute follow-ups each month and further follow-ups after that. So this takes time. It takes time to do it well—to do it holistically and to do it in a way that works with patients. Because of the problems of shame and stigma, which have been covered elsewhere, it has to be managed very sensitively.

GPs spend a lot of time treating people who are living with obesity. If you spend this money up front, particularly with a weight management wraparound, and you find that people are able to take those drugs and keep the weight down, is that not time-saving for you in the longer term?

Are you asking if it is time-saving if they are on drugs, compared with not being on drugs?

Yes, or even if they are on the drugs, and then they come off them and keep the weight down, would that not save time for you in the long term rather than having to deal with people who are living with obesity—or is it too soon to measure that?

Exactly. We also need long-term data here; we do not have the full long-term data. Yes, there is a role for these drugs and there are patients who they can make a big difference to, but, as we have covered, that does not change the need for wraparound care or the issue of environment. We are sending patients home to an environment that is making them unwell.

Yes. Dr McCullough, do you have anything to add to that?

One thing I would touch on is workforce. Dr Stewart will know more about this than I do, but if we are suggesting that the bulk of weight management should be done in primary care and by community providers—and I think there is a role for community providers in this—we need a robust workforce plan going forward, and to my knowledge, that has not been done. That plan would need to take account of specialist services as well.

We are waiting for the workforce plan. Obviously, the 10-year plan talks about “a moonshot to end the obesity epidemic”, and there will be workforce implications in that. Is it your understanding, from talking to the Government, that they will take weight management issues and the workforce needs around that into account when they produce the plan?

I hope so, but I hope that they do it with the correct assumptions made. As has been alluded to, there are a lot of unknowns on the long-term outcomes of various interventions. In specialist weight management services, we know that access to psychology, for example, can be difficult. We really need to look at expanding and increasing the use of bariatric surgery in specialist weight management services. There is a lot of good evidence for bariatric surgery, and for the good long-term outcomes of it; we do not have that same kind of evidence for weight loss medication yet.

From what I am hearing from many people this morning—the Chair pressed helpfully on the underlying biology—it is still a lot better to ensure that people are not subject to adverts pumping rubbish food at them all day long and are not eating unhealthy things that make them ill and cause obesity, so there is still a lot of preventive work to be done.

Absolutely. You talked about the moonshot, and the thing I would say is that it is a moonshot to “cure” obesity, but cure means reliance on treatment. We need to go further than that; it needs to be a moonshot to prevent obesity and overweight in the first place. We must not forget about prevention and just rely on treatment options. You can talk about a few things: yes, we welcome such things as the sugar tax levies, the watershed marketing, marketing around schools and childhood advertising. There are lots of different ways in which we can tackle this that are beyond just treatment or telling people to eat less and exercise more. We need to move beyond that notion, and focus intervention particularly in areas of deprivation, where we know that health inequalities contribute to obesity.

We do not want to be in a position where doctors are having to work ever harder to treat more and more unwell people with more drugs, so yes, prevention is still essential.

The Government obviously have prevention as one of their three big shifts—that is a statement and it is in the 10-year plan. How far do you think the measures that the Government have come out with support prevention, as opposed to focusing on medical solutions?

Exactly. We cannot think in one silo about looking at prevention being about the NHS. We need to look at policy much more widely.

How confident are you that the Government are focusing enough on the third pillar of prevention?

In the context of obesity.

I think a lot more needs to be done on prevention.

And would that involve things around advertising?

Yes. Again, I would refer to the Obesity Health Alliance. They have suggestions on advertising, access to exercise and safe places to exercise nearby. It is also about recognising that this is partly about poverty. Not every case of obesity is related to poverty, but poverty relates to your space, your availability to prepare and store food, the stress and the effects of lack of sleep. There are wider determinants that are relevant, but they are also things that can be tackled.

I have two doctors in front of me, which is one of the joys of being on the Committee. I want to ask a question that bugs me a lot. Everyone goes on about eating less—that the cure is to eat less and more healthily, if you can afford it, and to do exercise. If you had to balance the relative importance for fighting obesity of people eating less or doing more exercise, on a scale of one to 10, how important is eating less and how important is exercise?

For children, exercise is more important. I could start with that as something that is easier to be clear on.

For adults?

For adults that is more difficult. I would put them more in balance.

There is certainly a role for appetite suppression, as we know from these drugs that predominantly work on appetite suppression centres in the brain for adults in terms of weight loss. But this is the importance of wraparound care. It is not just about food intake; it is about the quality of food and nutrition that we eat.

So it is food, not exercise, that matters.

It is both, but in adults it appears, from my knowledge, that it is the food quality and quantity, but exercise is really important. The CMO’s advice on that is very clear, in terms of exercise as well.

I just worry that people are going to be encouraged to spend lots of money on going to the gym but still eat crap food.

That’s my method.

One of the things we do not know is the impact of these drugs longer term, particularly in patients as they get older. Within obesity circles, there is concern about something called sarcopenic obesity and muscle wasting. Resistance training and things like that are an increasing area that people are looking at.

You have already touched on this, but I would like to come back to private providers of these medications. You said there is an implication for your workload from people going to private providers. Could you expand on that? What sort of quantity of casework are you seeing coming through? Is the quantity of casework coming from private providers for this particular area more than for other clinical areas that you experience?

The biggest is probably around these at the moment. It is a significant workload implication. We recognise that patients are trying to improve their health and we want to support them with their health. We are seeing people with a range of experiences. We will have people coming to us who have had side effects of these drugs that have been prescribed privately, and then they come to us. This is important but it is work that has been created that we are not getting extra funding for. We have also seen patients who have had their lives transformed and it is useful to be able to give balance, to be fair, that this has been helpful for them. We will also have patients who have been prescribed it and there is perhaps an interaction with a medication that they are already on, such as contraception or HRT, and that has a workload implication as well. The figure from a pulse survey was that GPs are finding that one in 25 appointments now involve a Mounjaro discussion, either as the main reason or an add-on to other issues.

From what you are saying, it does not sound like this is an optimal way to put weight loss jabs through a health system, in that it is adding to your workload. From what I understand, you are having to say, “Yes, these people can have the weight loss jab,” but private providers do not have access to medical records currently. Is that right?

They will largely be relying on what the patient tells them. But an even bigger concern is the inequality. We have a system where, if you can afford it, you can get access to something that improves your health. If you cannot afford it, you do not have access because, importantly, the criteria for prescription are not set by GPs. The new QOF targets and incentives do not change our criteria for what we can prescribe and when we can refer, but patients often think that we are the barriers to that. That also has a workload implication because people will come to us saying, “Why can’t I get this drug?”

Do you think there should be more data sharing in this area between the NHS and private providers? Do you think that is a reasonable thing? Dr McCullough, do you have any thoughts on that?

I think that data sharing in general needs to be improved, as that would benefit the patient—obviously, with their consent. I just want to come in on your previous comment. There is also an impact on specialist weight management services, which are exempt from the funding variation. According to NICE guidance, specialist weight management services should be in a position to provide Mounjaro to those with a BMI of over 35 and one comorbidity. People who are obtaining it privately go and see their GP and, depending on the ICB commissioning criteria, they may or may not qualify. There has been a significant increase in demand and in the referral rates to specialist weight management services, which already have long waiting lists, so there is also an impact there.

Moving the conversation on a bit, I just want to get your thoughts and feedback, based on your patient lists and experience, about how private providers market their products. There have been various television programmes and newspaper articles about it, and it involves social media and influencers. Young people, in particular, are being persuaded to start accessing these drugs with discount codes, and then the prices become incredibly expensive. What are your experiences of that, as frontline clinicians?

I also work in acute medicine—frontline in the hospital in A&E—and we have certainly seen an increase in the number of people coming to emergency departments with side effects from the whole class of drugs, so it is an issue. When I teach or do conferences, my message is, “Don’t assume that somebody in front of you needs to be obese or overweight to be taking these drugs.” If you want to get your hands on these medications, it is very easy to do so on some platforms. There are some platforms that ask people to show a photo of themselves. There are some really quite dubious practices, although it is not all of them—some are very good and provide very good wraparound care too; it is variable. That is the issue. In terms of marketing and advertising, you just need to go on Instagram or wherever. It is very, very easy, and once you click on one, that’s it—you get lots and lots. It is very easy and it is not regulated. That is concerning.

This is probably a rhetorical question, but let’s go for it anyway so it is on the record. Given that the situation is as you say it is, it sounds like you would strongly advocate for much stronger regulation in this area to ensure that it is simply not possible for people to go on to social media sites and access these medications.

Yes, I would.

I would just like to add a comment about the expectations of patients and policymakers. We need to be careful about ensuring that everyone is aware that these medications are not a silver bullet. I think that is how they are being understood by many.

Turning to the workforce, why doesn’t obesity have its own specialty? Should that change, and, if so, what impact do you think having a specific specialty within the royal colleges would have on treatment outcomes for obesity?

Yes, we would support that. You are absolutely right. For example, bariatric surgeons usually go down the general surgery training route; should they then be interested in bariatrics, that is where they go, but there is no formal training programme in the UK. Most bariatric physicians have a diabetes and endocrine background; that is the extent of their formal qualifications. There are accreditation courses. Probably the best known is SCOPE, which is run by the World Obesity Federation, but there are various others. You are absolutely right, and it is something that the Royal College of Physicians would support so that it is standardised and we get the right skill mix and expertise in workforces to deliver what is an increasing need.

Just to take what you are saying further, what demonstrable impact would that have on how services are delivered and the outcomes for patients?

It would mean better patient care, because you would have a workforce knowledgeable about the latest treatment options and signposting. You need training in the holistic provision of care in a caring, compassionate, non-stigmatising manner. Unfortunately, not all healthcare professionals do that. At the royal college, we have recently launched e-learning modules in obesity for healthcare providers—it is not restricted just to physicians; it is for any healthcare or allied healthcare professional—and we are building on that.

Obesity is complex; it spans several different specialties, and to me that would partly emphasise the benefit of a generalist—a general practitioner. I refer back to comments that the previous panel made on patients feeling abandoned. When general practice is done well, the continuity from it is the answer to that. It is a GP the patient trusts, who knows the patient well, and that is an answer to many of these problems.

I am going to delve into that in a minute. Obviously, GPs can also specialise—not in the same way as in hospital medicine, but you can have areas of specialty within general practice. Could there be specialty GPs for obesity, as there are for older people and so on?

First, I would point out that general practice is a specialty.

Sorry—within the specialty.

But yes, you are quite right: there could be an extended role for a general practitioner in obesity.

As a GP, would you welcome an obesity specialty separate from those working in hospital settings and the acute sector—secondary care?

We found the Royal College of Physicians’ suggestion of two tiers of care sensible. If that second tier is a specialist in obesity, that seems sensible.

Moving on to what you just mentioned, Dr Stewart, we held a roundtable with people who had experience of accessing weight loss management and treatment. A lot of them said that they had to essentially fight to get the treatment in the first place, and many of them felt that the healthcare professionals they interacted with did not know enough about the treatment options. My question was going to be, do you recognise that? But you have just said you do, so what do you think is driving the lack of knowledge, and how can we go about changing that?

We have been campaigning for years on having more than a three-year training programme for general practice. We also do not have funded time for professional development as GPs. As a college, we have put in place an obesity hub to improve knowledge and care. Those would probably be the key points.

Dr McCullough, do you have a view on this, with your experience?

All I would say is that obesity touches on pretty much every specialty within secondary care medicine, and therefore leaving it to diabetes and endocrinology for the large part seems slightly short-sighted. Whether it be orthopaedic surgeons and MSK, cardiologists or gastroenterologists, it touches on pretty much every specialty. We would like to see that really ingrained in training. We obviously welcome that it is being taught in medical schools. I would also argue, while we are on the topic of education, that this needs to start in childhood. Children in primary schools and secondary schools should be learning about the importance of healthy eating and exercise. We recently published a paper on maternal obesity, which outlines seven key areas of intervention. One of those is education, starting early and throughout somebody’s life course.

I am going to follow on from Greg. We held a number of roundtables a few weeks ago. I am sure you would agree that health professional training is absolutely key, but a number of the people at the roundtable felt that that was lacking. Many of them felt that health professionals’ knowledge of weight management was very limited—I’ll leave it at that. Where do you feel are the opportunities to add obesity-related training to support healthcare professionals? What should that training be? What do you feel would make health professionals far more professional in the work that they do?

Finding the time is the problem. In hospitals, consultants will have a session or more for professional development. We do not have that in general practice. That is part of our barrier to improving general practice because it is essential that we keep up to date with the latest evidence and provide the best care. GPs need time to do that, and we do not have that time. Over 70% of GPs say that they do not have the time to provide the health and motion advice that they want to give to patients, let alone the time to then go on and learn about the latest in obesity care. Yes, we want to provide the best care. The information is there; we try to provide it and we should be providing it, but there are barriers that make it difficult for GPs.

Before I move on to Kath, I should say that I am struggling with all this because I have been reading everywhere, and in the notes, that obesity is definitely like diabetes—it is a problem. Doctors probably see more obese people than people that are not living with obesity, so why is it not seen as a priority to at least get the development and training that GPs need? Is it that it was not in the GP contract, so it is not a priority on that front, even though things are changing? Is it that doctors, although busy, see obesity as the patient’s problem? What do you think are the issues that mean that they do not see this as a priority?

I think that is a fair challenge. There is a gap between the quality of care and what there needs to be. I guess that GPs could provide better care. We could have better knowledge. We also know that there is stigma, and stigma does not help anywhere. I have a lot of experience of seeing it done well. I try to do it well myself and we try to educate our colleagues to do it better. The challenge is fair. It is probably not just a problem across general practice but maybe linked back to why public health measures have failed over the years. It is because there is too much stigma on individual patients and not enough understanding that 40% to 70% of the disposition to obesity is genetic—and then it is the environment. Yes, I think that GPs need to have better knowledge. I have tried to find points where we could improve that, such as with longer training. It is in the curriculum, but we could make sure that it is in there. We should have the CPD time for GPs to stay up to date and provide the resources for GPs to make sure that they have the right information. I think that is a fair challenge.

I will go to you, Dr McCullough.

I agree with what has been said but the obesity space has hugely changed over the last decade. One of the very positive things about the new medical therapies is that people are talking about obesity. There is now increasing recognition, among not just the general public but healthcare professionals, of the harms associated with living with obesity. Within a secondary care environment, there definitely needs to be more in the way of education. At conferences there is usually a topic somewhere that relates to obesity and the importance of it. There needs to be better recognition and understanding of it among clinicians themselves. For example, in our local area I do quite a lot of talks for GPs, and sometimes they have lunchtime opportunities.

Can I butt in there? It is not just GPs.

Absolutely.

I am no longer a nurse; I am a retired nurse, but I was a nurse for many years. I never had any training or guidance on the subject. I know GLP-1s have just come out—in the last 12 to 18 months they have become the big new thing—but this is about more than just the GP. Across the health service there seems to be a problem with getting professionals up to speed in this area.

Absolutely. That is also true of, particularly, secondary care specialists not feeling that they have a responsibility to discuss weight with their patients in a holistic way and to refer on as appropriate. I think that it is really important that every healthcare professional sees that as their responsibility, as the ambassador for that patient. You are absolutely right: it is not just primary and secondary care colleagues. Maybe this is an opportunity to look at training. We are very fortunate in secondary care that we have time allocated for continuing professional development. In statutory and mandatory training, we already have the very good, robust Oliver McGowan training being rolled out nationally. Should we look at a set of training modules to be made mandatory for healthcare professionals? That is maybe something to look at.

That is a very good point. My next question follows on from that: do you think that Government have a role in this? Should we be legislating that more needs to be done, or should it be done through an ICB lens—or just through the NHS? Where should the pressure come from?

We know from the 10-year health plan that there is more of a focus on local and regional levels. Where it can work well nationally is if you have got guidance, a framework or a set of principles for how it should be delivered. In terms of responsibility, delivering any kind of outcome like this, when it comes to education, probably needs to sit locally, because the organisations there know their population needs best.

Dr Stewart, I will go back to the Government lens. What role do you feel the Government have in supporting healthcare professionals to have more effective and evidence-based conversations with their patients?

I would come back to the investment to allow GPs to have time for professional development, which is essential to ensure that GPs are up to date and educated. We also need the tools to do the job, in terms of the number of GPs and resources. We are beyond capacity and struggling in general practice. Those are two areas that rely on Government to be able to do the job. I will have patients who come in with three, four or five problems, and I have a 10-minute appointment; if obesity is the fourth or fifth thing they mention and we do not deal with it then, I will usually get them started and ask them to come back. But there is only so much that GPs can do, so a big part of it is the resourcing for general practice.

I would also say that we do not just need to rely on doctors. As you said, there are fantastic nurse specialists and community pharmacists. It is about having the right mix of workforce and appropriate skills. It does not necessarily have to be doctors.

Dr McCullough, you have literally come in ahead of me, because my last point is that I believe it is not holistic enough. You have got some phenomenal pharmacists out there, and there are some excellent practice nurses and others. How could the system be more joined up? I will start with you, Dr McCullough, and then Dr Stewart will have the last word.

In terms of how we can join it up and education, it goes back to how we work in silos. We need to be much better at working together as a team across primary care and community, and that should be done at an ICB level. Currently, there is a lot of upheaval within ICBs, and there is also clustering going ahead. But I see that clustering as an opportunity to review what weight management services are available and come together to decide what the best thing for the patients going forward is.

I would take this opportunity to ensure that these resources and services are based on need and inequality. Yes, there is a role for MDT, and yes, we need resourced services. So that we do not see weight loss drugs as a replacement for services, we need the wraparound care and the investment in those services as well.

I have one quick follow-up question. As a data-gathering exercise for the Committee ahead of this inquiry, we asked people about their interactions with GPs in this area. The results were quite striking. First, on a very positive note, 21.8% of people who responded to us said that their GP was kind and encouraging. For example, one respondent said, “he understood I knew what I was talking about and encouraged me to keep going. He offered additional support”. That is all positive stuff. I feel like we have been speaking to people today who have a particular interest, and are doing this well, as I think you said, Dr Stewart. But I was dismayed to hear that 28.7% of people—statistically more or less equal—felt stigma and a negative emotional impact from speaking to their GPs. They felt shamed, humiliated and blamed. Words that came up included “embarrassed” and feeling “like a failure”. This is a quote which is really worth reading out: “Ashamed—even though I try so hard to lose weight, I’m always told that it’s my fault that I haven’t been able to. It makes me feel like a complete failure, and like there’s no point in ever trying—maybe I’m just destined to be like this forever? I worry for my health and for my kids if I get sick, but I feel like there’s nothing anyone can do about my weight. I feel alone, and I feel guilty…” This was specifically after being asked, “Following your interaction with your GP about this, how did it make you feel?” and it came under the headline “ashamed”. There is a cultural issue here, is there not? We cannot change the culture of society in one hearing, although we would like to try. I would like to think that in this room we might have some influence on the culture among general practitioners, who are very much the front door. What do we need to do to change the culture among GPs? I hear what you are saying about more training and so on, but this is a huge prevalence—64% are living overweight or with obesity. That is not good enough, is it? What do we need to do? Is defining it as a disease the way to make GPs take this seriously, for example? If it is not that, what is it? I do not accept that this slowly, slowly, softly approach that we have been taking so far is working. If GPs do not get it, how on earth can we expect the rest of society to understand that this is a real issue and that we need to take it seriously, rather than having these kinds of interactions?

It is not acceptable for a patient to go to the healthcare professional they trust and to come away feeling worse. We have to improve that as GPs. We also have to improve it culturally because it is widespread that individuals are blamed for obesity, and that is not helpful. That comes from all levels. Yes, it comes from general practice, and we have to get that message out. We have produced learning materials to try to do that. However, it also needs to come from the highest level in terms of public health policy, pointing out that it is not a disease of choice or lifestyle, but one of genetics and environment.

So would you agree that we should be defining it as a disease?

I just realised I used the word “disease” there—

I heard you say that—would that be a helpful signal to your colleagues that this is, in the same way that someone might treat diabetes or cancer, something that should be treated clinically in that way rather than being a judgment, which is what some of the patients have felt? Would that be helpful?

I am not sure. I have listened to the previous panel with interest, and I think we have always referred to it as a “condition”. How much of a difference using the word “disease” would make, I am not sure. I think it is about all of us saying that it is because of genetics and environment, not because of individual failures of willpower. That is all our responsibility.

It is very sad to hear a quote like that, if I am honest. That is absolutely not—

I am sorry. We pulled it out because it was not the only one.

It is very powerful. In secondary care, we sadly hear the same thing—not just from primary care colleagues, but from secondary care colleagues. It needs to be part of training at a very early stage for healthcare professionals. As Dr Stewart just alluded to, this is not anybody’s fault. This is a complex condition, with many different factors involved, including deprivation and underlying genetics, as more evidence is coming through. If we can get that through at an early stage in medical training, that would be helpful. As leaders—when I talk about leaders, I talk about secondary care—and as consultants, that needs to be conveyed to the resident doctors coming through that language really does matter. It is important and we can set that standard. At the Royal College, that is what we have tried to do through these e-learning modules and hopefully with time that will start to filter through. As leaders, we have an opportunity and a responsibility to start framing that language and consider those interactions with people living with obesity, which are absolutely key to their experiences, as you have alluded to.

Thank you very much and thank you for your time. That brings us to the end of our session.