Commissioning of Tier 3 obesity services by Integrated Care Boards in England: an analysis of responses to Freedom of Information requests
Authors: Finer Nicholas , Fragkas Nikolaos , Miras Alexander Dimitri , Le Brocq Sarah , Pournaras Dimitri J , Wass John , Pyper Cecilia 
Published: December 2024

Objectives

This research surveyed Tier 3 adult weight management services in England commissioned by integrated care boards (ICBs) across England in financial year 2022-2023.

Design

Survey of public health services commissioned by ICBs gathered via freedom of information requests

Setting and Participants

All 42 ICBs in England

Primary and secondary outcome measures

The primary outcome measure was whether or not there was Tier 3 provision. Secondary outcome measures included the type of Tier 3 services provided and the estimated number of patients referred and treated.

Results

We received responses from all 42 ICBs, a 100% response rate. Five reported that their ICB had no Tier 3 provision (NHS NW London, NC London, Lancashire and South Cumbria, Northeast and North Cumbria, and Northamptonshire).

Deprivation is the major underlying inequality underpinning differences in obesity levels (24, 25), so we explored the relationship with deprivation measured by the Index of Multiple Deprivation (IMD) for each ICB and referral rates to Tier 3 services. Including only data from those ICBs returning numbers of referrals identified there was no correlation between IMD and referral rates (R2= 0.074; P=0.210).

Since obesity prevalence data mapped to ICB level was not available we used regional data and estimated that 25% of people with obesity were likely to have a BMI≥35 kg/m2and be eligible for referral to Tier 3 management. We then calculated the percentage receiving treatment. According to ICN reports the percentage of eligible patients treated ranged from 0 to 1.1%, the highest number was in the South East of England, a region with the lowest levels of deprivation.

Lastly, we noted that, several ICBs were commissioning services that appear to not meet the definition of a Tier 3 service and were more in keeping with the criteria for a Tier 2 service. Accessing full details for these programmes is currently not readily available. However, treatment programmes exclusively online may fail to: be complete in their multidisciplinary team; provide clinical assessment and screening for obesity related diseases; include access to pharmacotherapy or surgery or comply with NICE guidance.

Conclusions

Provision of Tier 3 services in England is inadequate and variable and they currently fail to meet the needs of the population. Five ICBs provide no Tier 3 services at all. Areas with highest levels of deprivation provided the most limited access. Even where commissioned, services often do not meet commissioning guidelines. Action is required to implement Health Service Policy and to ensure obesity services conform with clinical need and national guidelines.

Strengths and Limitations of this study

The study covered all ICBs in England giving an accurate overview of Tier 3 services in financial year 2022-2023.

The findings rely on the accuracy of the data supplied by the ICBs, which could not be verified.

Relevant measures of population health including ethnicity, the prevalence of obesity across England and areas of deprivation were used to assess potential need for AWM services across England.

The study took into account services commissioned from private Tier 3 service providers.

The period covered was soon after ICBs took responsibility for commissioning Tier 3 services, and in many cases had yet to appoint an ‘obesity lead’, despite their roles and responsibilities being laid out in May 2022.

In October 2023 and March 2024, NICE approved 7 digital services for prescribing and monitoring and delivering multidisciplinary weight-management services. These value assessments post-dated our survey dates and were not aligned to the definition of Tier 3 services.