To develop an evidence-based adult obesity care pathway collaboratively across NHS Bassetlaw Primary Care General Practices and to ensure successful implementation and evaluation of the pathway within primary care. The evaluation of the effectiveness of implementing the care pathway using qualitative and quantitative methods should lead to identifying ways to improve & implement improved care pathways further.
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Aims and objectives
Provide an accessible, credible, recognisable service for overweight Adults in Bassetlaw that is beneficial & helps support them in making lifestyle improvements to improve longer term health. The service was designed to follow the guidance CG43. Also we wanted the service to meet and exceed the requirements of the local NHS Bassetlaw Specification. Staff selection & accredited training were important. We wanted a service that patients were aware of, knew how to access, was valued, & could demonstrate long term, sustainable health benefit. We aimed to extend the access of the service to other General Practices in Bassetlaw, & beyond. We developed a standard service pack & supporting educational materials for each course leader. We worked closely with NHS Bassetlaw's Public Health team to share our knowledge & expertise, with regular audits of progress. We also held regular service reviews with staff. These were important so that we might achieve better results. We set out to develop working partnerships with local organisations including DC leisure facilities & voluntary sector organisations. We wanted a multidisciplinary team that could be innovative in its approach to services.
- Develop an evidence-based Adult obesity care pathway that met CG43 & NHS Bassetlaw specification
- Develop a service with long-term sustainable benefits for patient, monitored by conducting 3 & 12 months follow ups
- Develop a service with better outcomes than other comparable services
- Develop service brand & identity that is recognisable & trusted
- Ensure staff are recruited & trained to deliver high standards
- Provide choice (different days, times and locations of delivery)
- Develop an effective patient & commissioner communications & feedback systems
- Evaluate effectiveness of pathway, with regular audits & reviews with Public Health & staff
- Develop independent academic assessment of the service & promote opportunities for academic studies, placements & evaluation, & gain independent recognition
- Identify service improvements from regular audits
- Expand delivery initially from 4 general practices
- Consider innovations in services based upon results, outcomes & feedback
- Identify key success factors for further implementation in other areas
- Develop partnerships with other organisations to help support lifestyle improvements
- Maximise opportunities for meeting QIPP agenda
- Involve staff & patients in improving services
Reasons for implementing your project
Obesity is a problem and seen as a major priority. Local Area Agreements & the Bassetlaw Strategic Partnership for Health (2009-2011) cite the need to try to tackle this. Part of the Bassetlaw Local Strategic Partnership (BLSP) planned objectives and actions to reduce obesity, is to supply the development of initiatives to help people to lose weight and /or maintain weight. As a result an accredited weight management programme has been developed, so that Clinical staff can participate in this programme with a view to developing evidence based weight management programmes. Tangible measures and outcomes form part of the BLSP.
The PCT launched a Locally Enhanced Service (LES) at the end of 2008 to encourage Primary Care providers to develop accredited weight management group programmes of excellence to help to address the problem. During a baseline assessment a number of key problem areas were identified: service provision varied across the PCT and within general practice. Staff were often not trained, services under resourced and over-referred (e.g. dietetics), and in some cases not provided at all or provided very inefficiently e.g. 1 to 1 clinics. The management of patients was not systematic and structured, there was a lack of audit information about clinic results and outcomes. Patients were not provided with first line advice prior to drug treatment.
An obesity care pathway was developed to translate the NICE guidance into a local service, which could be implemented and audited within primary care. As a result a collaborative approach to service delivery was developed to provide more patient choice, a more efficient service and one with clear audited results and regular reviews. The NICE guidance sets out broad guidelines on structure, length, scope and which patients to target. It also sets out the key indicators to measure and the areas of lifestyle to improve.
Our involvement with patients and stakeholders was to work collaboratively with a multidisciplinary team (including GP, Nurse, Business Manager, Public Health Lead, Administration and Practice Managers, Patient Representative Group) and then to agree a communications plan and service outline. A pilot patient group was set up and the results of this group closely monitored. Patient feedback was sought at the end of each weekly session. A review of course content structure was held, and changes made.
How did you implement the project
The Public Health lead developed a PCT specification based upon the guidelines of CG43, for
practices to sign up to and to agree to contract to. We set up a multidisciplinary development team
consisting of a GP, Business Manager, 2 Practice Nurses and a front line reception team leader.
2. We developed brand and corporate identity for the service & called it Chrysalis
3. We developed communications materials for promotion through clinicians (GP's, Nurses), and information leaflets for patients. We developed press release information and display banners to raise awareness.
4. We developed a structured presentation based programme for small groups to attend over a 12 week period, and set up administration to capture patient interest. We devised a patient education pack & personal plan to provide information and support for each of the 12 weeks of the programme. This was developed to meet the requirements of the NHS Bassetlaw LES and NICE CG43. We devised appropriate data capture for monitoring patient attendance and weight loss progress, as well as post programme follow up.
5. Pre-assessment appointments were set up for patients eligibility and motivation/willingness to change and for baseline data capture.
6. We identified rooms and appropriate staff for delivery and purchased presentation equipment for small groups to attend.
7. We started a pilot group of 10 patients and reviewed each session, progress and materials. We sought patient feedback from attendees completing the programme and those that did not complete.
8. Due to the success & interest in the programme a patient waiting list developed & we had to recruit & train new staff to provide the required capacity.
9. We offered a range of days & times for patients to attend including evenings
10. We reviewed results quarterly & communicated these to public health teams, & critically analysed results.
11. We developed partnerships with local leisure centres to provide opportunities for exercise, delivered in partnership with our course leaders.
12. We sought funding for an online calorie comparator, to provide additional support for patients.
13. We submitted a review to NHS Alliance and won a national award for local health improvement.
14. We developed collaborative links with Lincoln University.
We incurred costs of time setting up the programme, promotional materials equipment and handouts/course materials. We estimate that the set up costs for the programme were £12,000.
Putting CG43 into practice provided a credible structure for service design, content, patient eligibility, outcomes, subsequent analysis & evaluation. It enabled a consistent approach to be taken for service delivery. By encouraging predominantly group based interventions, there was a big impact on productivity & effectiveness of the group outcomes, lowering costs.
1. Enquiries are captured & baseline data measured, demographics, weight, height, Bloods, BP, medical history. Attendance & weights recorded weekly. Patient satisfaction monitored for completers & non-completers.
2. Quarterly analysis reported to practices & public health.
3. After 3 years we have seen 2,014 patients, 86% lost weight. 80% attend 6 or more of 12 sessions, 65% of these achieve 5% weight loss over 12 weeks (av.11.2lbs lost). After 12 months 77% of (378 Patients reviewed) who attended are at a lower weight than when they started, & 50% have maintained or lost more weight. 80% of patients are women.
4. Service extended to 8 practices
5. Patient feedback excellent, especially compared to other weight loss programmes
6. Independent evaluation by Lincoln University, confirms Patient success & satisfaction.
7. Online calorie comparator launched & patients using achieve better results than average.
8. Simple exercise class set up.
9. We developed modified interventions for patients with BMI 40+ (called Chrysalis PLUS) & learning disabilities, following our evaluation, which showed these groups performed less well. We have seen 30 patients with BMI 40+ who attended Chrysalis, but did not achieve 5% target weight loss. In the modified intervention (based on psychological support) 15 of these now achieved at least 5% weight loss, & are maintaining loss. The first pilot group for learning disabilities is showing good results (all patient's & some carers lost weight).
We want to extend this to other groups such as men & young people under the age 30.
10. We set up a service for Teenagers (Inneraktiv) & their parents based upon Chrysalis, with more activity. Results are excellent.
11. Compared to previous PCT Obesity results, Chrysalis weight loss is approx double that previously achieved. There is a lack of data on whether this was sustained after 12 months. Staff utilisation has improved by 200%+. Patients reported being healthier (81% better diet, 70% more active, 60% lower BP) lower medication, lower blood cholesterol & BP, lower BMI between 1.5 & 2.0 over the 12 weeks.
Key learning points
1. Patient communications about services are vitally important. Clinicians have much to deal with, when seeing patients, so making them aware is important. Messages need to be refreshed & revisited frequently. System templates to flag up eligible patients is helpful.
2. The service design is best achieved with a multidisciplinary team to ensure it meets the requirements of CG43 & the local NHS/practice needs.
3. Branding of the service has been very important as Patients like the club/social feel of our groups. They are proud also to be associated with a successful service.
4. Staff selection & training is key, our course leaders lead a healthy life & are active, so make credible role models.
5. We provide activity opportunities with known, trusted course leaders.
6. Motivation, confidence & readiness to change are important to check patients can succeed. Our pre-assessment appointment is a key element of the service, & this is best undertaken by staff that deliver programmes & fully understand them. Otherwise patients are uninformed, questions not comprehensively answered & drop out rates go up.
7. Clear & simple data capture at pre-assessment & during the running of programmes is important.
8. Patients need a choice of days & times to attend
9. Feedback on how individuals & group progress (anonymous) is helpful in maintaining motivation. Recognise & reward success (eg certificates of achievement).
10. Good administrative back up is essential in maintaining attendance levels, & ensuring that Patients return for 3 & 12 month follow ups.
11. Regular audits of progress & feedback to commissioners & public health teams is important as well as for clinicians. Independent recognition has value. This is a valuable source for good public relations.
12. Online & accessible information is a valuable support.
13. Segmenting patients into targeted groups e.g. young people, BMI 40+ gives better results.
14. Conduct regular service reviews
Is the example industry-sponsored in any way?