Dr Rachel Pryke: Arming GPs for the war on weight

RCGP clinical lead for nutrition Dr Rachel Pryke tells Stephen Robinson why general practice must prepare to fight obesity.

'I think this is a disaster that is happening around us,' says Dr Rachel Pryke. 'The problem had to blow up around us for people to notice.'

The Worcestershire GP understands the obesity crisis better than most. For the past three years, Dr Pryke has led an RCGP campaign to raise awareness of weight management in general practice.

The struggle is intensifying: the number of obese men in England has almost doubled since 1993 - a quarter now have a BMI >30 - and rates in women have risen from 16% to 25%.

Dire projections suggest that by 2050, every second person in the country could be obese, costing the UK £50bn a year and flooding general practice with complications.

Lack of leadership

Dr Pryke's appraisal of the NHS response to this threat is damning. A lack of national leadership, failure to commission support services and working in silos have resulted in a weak response to a huge problem.

Yet there are reasons to be optimistic, she insists, even if her words are peppered with realism about how much of a difference GPs can make.

Dr Pryke's interest in the matter began in 2006, when she wrote two books about a healthy diet for children and young people. She later joined the RCGP adolescent health group. This led her to propose the topic of obesity as a clinical priority for the college, one she led on from 2011 until the end of the programme this month.

She wants to challenge misconceptions about general practice's role in obesity care. 'There isn't a lot of confidence among GPs about how you can have an efficient and succinct discussion about weight or diet, because it's complex,' she says.

'How do we raise the issue? There's a lot of reluctance to talk about something that might cause offence.' Her advice is to begin by asking patients how they feel about their weight. 'That simple opener can change the nature of the conversation.'

QOF indicators for obesity have been proposed as a way of better engaging GPs, but were dismissed by NICE's QOF advisory committee.

Dr Pryke and colleagues are looking to push this agenda once again and have submitted indicators to NICE that link obesity care to an existing QOF domain. These could feature in a future GP contract.

However, she accepts that QOF may not be the right way to improve obesity care in the long term.

'We're very hampered by the old-fashioned siloed thinking about diseases,' she says. 'What QOF has tended to do is pitch one disease against another. I think we need to look forward to different mechanisms.'

Enhanced services may be one answer, and the RCGP has begun early discussions about this. Prevention could be a 'much more integral part of general practice', she says.

GPs' role

But should it be a GP's job to prevent patients from becoming obese? Dr Pryke thinks not: 'If you were to say GPs are responsible for the nation's weight, I would say that's nonsense.

'But if you were to say, what is our role in the wider approach in helping patients to be healthy, then you cannot argue (it isn't to) help somebody deal with a profound state of health that causes every other comorbidity going. That is just as much our job as it is measuring somebody's BP. It's about defining the expectation: that is where we need to work harder.'

Access to multidisciplinary support services that can accept GP referrals is patchy at best, a situation England's clinical director for obesity and diabetes, Professor Jonathan Valabhji, describes as 'unacceptable'.

Dr Pryke is equally scathing. 'This is where there is a very desperate need for leadership,' she argues, saying Public Health England (PHE) should be playing a larger part.

'PHE is hampered by localism. It's a nightmare if you're trying to set out a national directive,' she adds.

Child obesity services are particularly lacking, she says. 'Would the NHS say it is helping children with morbid obesity? I think it can judge itself.' Lack of access to services has a demoralising effect on GPs, she argues. 'Why would any GP risk what might be a difficult conversation, if they've got nothing to offer at the end of it?'

In spite of all the problems, there may be room for optimism. Figures suggest the rise in childhood obesity has slowed in recent years. Ideas such as a 'sugar tax' are also gaining traction, a move Dr Pryke supports.

She acknowledges general practice cannot singlehandedly solve the nation's obesity problem. But it can contribute a great deal.

A recent local strategy meeting brought a range of experts together, she says. 'Sometimes in the profession we don't see that. It's a shared agenda, and that's very much in our favour. We're not fighting this alone.'

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