The inclusion of obesity in the quality framework from April cannot be described as a difficult challenge for GPs so far. All you are asked to do is to set up and maintain a register of adults with a BMI of 30 and above to gain the maximum eight points for this domain.
But it is worth thinking about how the obesity domain may develop in the longer term.
Obesity is likely to have a much greater role in the framework, most probably in the context of a modifiable risk factor for cardiovascular disease (CVD) and diabetes and, therefore, a target for primary prevention.
In the UK, 29 per cent of men and 26 per cent of women are obese, as assessed by waist circumference. The treatment of this obesity is synonymous with the prevention of CVD and diabetes.
The quality framework has revolutionised the care of patients with chronic diseases and long-term medical conditions by linking it directly to financial rewards.
Our management of CVD and diabetes has never been better. But, however good our manipulation of lipids, BP and glycaemic control is for these patients, we are still treating the symptoms, not the cause.
The framework should reward us for identifying those individuals at risk of CVD and diabetes before the diagnosis is evident. The best and most cost-effective way to prevent the complications of diabetes is to prevent the condition in the first place.
Similarly, the best way to prevent a second MI is to prevent the first one. And the best simple way of identifying those at-risk individuals on whom we should target our scarce time and resources is by measuring waist circumference - given that this is directly proportional to cardiometabolic risk.
From April, the quality framework has recognised obesity as a medical condition in its own right.
While this is welcome, the condition has been added to the framework in an illogical and counterproductive way.
We are asked to recognise a significant physical sign of serious underlying pathology. The point of physical signs is as diagnosis aids.
We are asked to perform extra work, with no clinical benefit whatsoever, and at a significant financial cost to the health service.
As it is, the register is merely the reservoir from which we should be identifying those high-risk individuals at whom resources should be directed.
Although many motivated GPs will assess patients on the register further, this is essential work, and should be rewarded.
The next step in the process should be to screen all the patients on the register for fasting blood glucose, lipid profile and BP. We know that these factors have a tendency to cluster in the same individual.
The obesity register will provide rich pickings for discovering abnormal risk factors and allow accurate identification of a target population who will, in turn, populate domains such as hypertension or diabetes.
The first quality framework review has let down GPs by failing to reward financially the work of establishing who should be offered intervention as primary prevention of CVD by screening obese patients.
Evidence of risk
The evidence for more emphatic inclusion of obesity as a modifiable CVD risk factor is robust, and future revisions of the contract must reflect this.
Childhood obesity still does not garner a single quality point. The flawed measure of BMI in adults should be replaced, or at least be accompanied by waist circumference.
None of this is news to the GPC negotiators, who know that a register is neither use nor ornament unless it used for some intervention.
It is generally accepted that the inclusion of obesity in the quality framework is as an entry point for future revisions.
Cynics would say it is a way of sneaking obesity into the contract under our radar, only for our workload to be drastically increased following the next framework review.
Either way, GPs should not labour under the misapprehension that a register is all we will be asked for in the future. It is clear that as the quality framework evolves, the register will become a vehicle for further screening of obese patients.
- Dr Haslam is a GP in Hertfordshire and chairman of the National Obesity Forum, www.nationalobesityforum.org.uk
OBESITY IN THE QUALITY FRAMEWORK
- Waist circumference is increasingly recognised as the best marker for visceral adiposity and CVD risk and should be used routinely.
- It is likely to be included alongside BMI in the quality framework in the future.
- It is not acceptable to avoid assessing obese patients for fear of uncovering unwanted pathology. Screening of obese subjects is likely to be rewarded in the future.
- Opportunistic screening will increase numbers on the register dramatically, at the cost of a significant increase in workload.
- In future quality framework revisions, it is likely that each individual with one or more risk factors for CVD - abdominal obesity, dyslipidaemia, poor glycaemic control, hypertension - will be screened for the others.
Practice can produce a register of patients age 16 or over with a body-mass index higher than or equal to 30 in the previous 15 months.