Our practice has a list size of 9,288 patients. 2,766 (30%) have a body mass index above 30 kg/m2 (obese). In line with the National Institute for Health and Care Excellence (NICE) guidelines on obesity (CG189) and physical activity (PH54) we aimed to increase the use of our local exercise referral scheme (ERS).
Our patients are in a deprived ex-mining area where healthy lifestyle choices can be difficult. We designed an intervention to raise awareness of the ERS scheme amongst patients and staff (including clinical and non-clinical staff).
We strengthened links with our social prescriber, provider of the ERS scheme (the local sports centre) and implemented digital alerts on the electronic health record. We undertook digital and face-to-face training for staff and promoted the scheme via text messages and on the media board in the waiting room. Comparing ERS referrals before and after the intervention, we saw a 6-fold increase in referrals to the scheme.
Aims and objectives
Our study aimed to use a targeted intervention in a general practice setting to increase the number of obese patients referred to an exercise referral scheme (ERS).
We aimed to highlight the use of local, externally commissioned resources to promote health in the community amongst obese patients.
These aims were designed to implement guidance provided by the National Institute for Health and Care Excellence (NICE) Clinical Guideline [CG189]: Obesity: identification, assessment and management (sections 1.4 and 1.6), and NICE Public Health Guideline [PH54]: Physical activity: exercise referral schemes (Recommendation 2: Exercise referral for people who are sedentary or inactive and have a health condition or other health risk factors).
Reasons for implementing your project
Before we began our intervention, we noted that patients who were obese were not routinely offered a referral to the local exercise referral scheme (ERS). Baseline assessment showed just 0.5% adult obese patients were referred to ERS between October 2018 and September 2019. This ERS scheme existed to encourage patients to lose weight and improve their health and lifestyle in a safe environment, tailored to their medical conditions.
We have 9,288 patients registered at our practice. Approximately 2,766 patients are obese. Our practice population live in the 4th decile more deprived decile in England (measured by Index of Multiple Deprivation). We reviewed the NICE guidance for obesity and physical activity, which advises a referral to ERS for patients who are sedentary or inactive and have a health condition or other health risk factors (obesity). We engaged in discussions with a GP who works for the local commissioners and held talks with the local sports centre.
How did you implement the project
This project did not receive any specific funding. However, we had the full support of the partners of the Brierley Park Medical Centre and the local ERS provider (a sports centre).
Using the NICE guidance as a standard, we designed an intervention to increase ERS and raise awareness amongst staff and patients.
Staff were involved through education using the national ‘Making Every Contact Count’ framework in face-to-face sessions, which were consolidated through digital communications. We designed and implemented an alert on the electronic health records of patients who were obese, and we used an electronic text messaging service to text patients who were obese, inviting them to accept ERS. We used the electronic health records system (SystmOne) to identify adult patients who were obese.
Those patients who were referred to ERS were identified during the baseline period (1st November 2018 to 31st January 2019) and after the intervention had been implemented (1st November 2019 to 31st January 2020). We compared the numbers against the standard set in accordance with NICE Clinical Guideline [CG189]: Obesity: identification, assessment and management (sections 1.4 and 1.6) and NICE Public Health Guideline [PH54]: Physical activity: exercise referral schemes (Recommendation 2: Exercise referral for people who are sedentary or inactive and have a health condition or other health risk factors).
We subsequently used this guidance to form the rationale for the design of targeted interventions which aimed to increase the number of adult obese patients referred to the local ERS. We used the guidance outlined in CG189 involving the management of obesity with lifestyle interventions, such as physical activity, to underpin the selection of the target population.
We used the guidance outlined in PH54, which states referral to ERS should be made for patients who are sedentary or inactive and have a health condition or other health risk factors, as the basis for the review of ERS referrals. We did find that, initially, the administrators found it difficult to keep up with the increase in referrals and code the referrals correctly in the electronic health records.
Therefore, two doctors double entered and cross-checked the ERS referrals to ensure that our data was correct. However, we found under-reporting of the ERS after the intervention, rather than over-reporting.
We met our initial aims and objectives. The practice population as of 30th September 2019 was 9,288. Of these, 2,766 (30%) adult patients were recorded as obese prior to 30th September 2019. 62 adult patients (0.7%; 2% (% of total practice population; % of obese population)) had been referred to ERS between 1st October 2018 and 30th September 2019 as part of a healthy-living intervention.
48 (0.5%; 2%; 77% (% of total practice population; % of adult obese population; % of total adult 2018-2019 ERS referrals)) obese adult patients were referred to ERS between 1st October 2018 and 30th September 2019.
In our first cycle data (November 2018 – February 2019) we had 16 patients (0.2%; 0.6% (% of total practice population; % of obese population)) who had been referred. In our second cycle (November 2019 – February 2020) 96 patients (1%; 3% (% of total practice population; % of obese population) had been referred.
Comparison data from both snapshots demonstrates a five-fold increase in the number of referrals following implementation of the intervention.
Key learning points
Our study demonstrates an increase in referrals to the local ERS following the designated interventions. Our methods highlight the use of interventions to improve engagement with a local, underutilised community resource. We achieved this without additional funding, creating new services, or significantly increasing staff workload. However, this did rely on the overall team effort from a strong primary care team (both clinical and non-clinical).
In the future, we plan to further embed the ERS scheme in the practice building by advertising the scheme in our waiting room and inviting the sports centre to come to a public health promotion event at the practice. We plan to explore expanding our scheme to include patients who are listed for surgery. This is an initiative currently taking place in the local region in conjunction with the local district general hospital.
Obesity is a complex health issue, therefore ERS is only one facet of how our practice is dealing with this. Obesity is linked to social deprivation and poor mental health, which in themselves are interconnected. Our practice has involvement from the local Citizen’s Advice Bureau, social prescriber, mental health counsellor and is involved in the local park run. Societal attitudes towards diet and exercise have changed over the last few decades, in part by the marketing of increasingly unhealthy foods but also as a result of individuals having less time, creating demand for more convenience foods.
We continue to approach the issue of obesity using a population health approach, as well as using the ERS scheme.