Primary Care Service Framework: Management of Obesity in Primary Care
Primary Care Service Framework: Management of Obesity in Primary Care
§ to equip commissioners, providers and practitioners with the necessary background knowledge, service and implementation details to safely commission and deliver a high quality, integrated obesity management service in primary care.
§ as a means of improving patient’s health and quality of life by providing patient-centred, systematic and integrated support.
2. Period of Service / This service will run for a period of twelve months from 1st April 2007 – 31st March 2008 (extended subject to satisfactory annual review).
3. Scope and Definition of service / The service is open to male and female patients and will need to be tailored to either adults of children. It can be provided either at individual practice level, or on a locality or PCT basis. It is open to all types of providers for example, GP practices, Community Pharmacists, community and specialist nurse-led services, voluntary sector, Local Authority, the independent sector or other alternative providers. However, this Framework may achieve more success through an integrated and community based model, making best use of joint commissioning approaches and networks of provision.
This primary care service should not be confused with (and sits outside of) essential and additional GMS or PMS services already provided, current Quality and Outcomes (QOF) indicators and any National Enhanced Services.
4. Parties to the agreement / Insert names of any accountable individuals and organisation details.
5. Background / Obesity is the second most common preventable cause of death after smoking in Britain today and is responsible for more than 9,000 premature deaths per year in England. At present, more than half of the British adult population is overweight and obesity has trebled in the last 20 years to 22% of men and 23% of women. The same scale of problem is true for children also. There has been a 22% increase in overweight (including obese) and a 38% increase in childhood obesity since 1995. Forecasting Obesity to 2010 warns that if current trends continue more than a quarter of British Adults will be obese by 2010.
Obese people have an increased risk of dying prematurely or developing Cardiovascular Disease, Type 2 Diabetes, Hypertension, Dyslipidemia, some cancers, musculo-skeletal problems and other diseases.
Most evidence suggests that the main reason for the rising prevalence of overweight and obesity is a combination of less active lifestyles and changes in eating patterns. Both these factors must be tackled to produce reductions in obesity with even a modest weight loss of 5-10% of body weight in an obese or overweight person resulting in health and well-being benefits.
The ‘Choosing Health’ White Paper (2004) recognised obesity as a key priority and included a commitment to ‘halt the year-on-year rise in obesity among children under 11 by 2010, in the context of a broader strategy to tackle obesity in the population as a whole’. This is monitored through a national Public Service Agreement target. The NSF for Diabetes (DH, 2000) also sets targets for the reduction of overweight and obesity and for the promotion of healthier eating. The NHS Cancer Plan (DH, 2000) and the NHS Plan (DH, 2000) both set targets to increase access to and the consumption of fruit and vegetables. The ‘Our Health, Our Care, Our Say: a new direction for community services’ White Paper (2006) emphasises greater service integration with a wider access to services closer to patients’ homes.
NICE has recently published guidance on the prevention, identification, assessment and management of obesity in adults and children - www.nice.org.uk/guidance/CG43/. A complementary evidence base and resources to support this service development can also be found via the ‘Care pathway for the management of overweight and obesity’ www.dh.gov.uk/obesity and a supportive toolkit developed by the Faculty of Public Health and the National Heart Forum entitled ‘Lightening the Load – tackling overweight and obesity’ www.fphm.org.uk is also available.
6. Summary of Local Need / Commissioners should outline or reinforce a summary of local health and social care or service need drawn from a Joint Strategic Needs Assessment, done with Local Authority partners. Suggested options to include here can be found in the additional notes below.
7. Service Objectives and Intended Health Outcomes / Joint working between service providers is critical to achieving the following list of service objectives and intended health outcomes for the local population:
§ To reduce obesity levels in patients who have a Body Mass Index (BMI) greater than 30 (or 28 in Asian population)
§ To improve diet and nutrition, promote healthy weight and increase levels of physical activity in overweight or obese patients.
§ To promote better obesity management among health care and other professionals.
§ To reduce BMI levels in areas where there are particularly high levels of health inequality.
§ To improve access to overweight and obesity management services in primary care.
§ To establish an up-to-date and complete register of BMI for appropriately targeted populations.
§ To raise awareness among patients and their families of the health problems associated with obesity so they can take more responsibility for their own health.
§ To raise awareness among partner services necessary to support first contact service providers, helping achieve a more integrated service.
§ To provide targeted advice and referrals for patients with chronic or longstanding overweight or obesity.
8. Service Outline / To encourage the early identification of overweight and obese patients, the scale of the problem locally and on-going service provision in a more manageable way, it may be appropriate to agree with providers an approach to delivery which begins at the most basic level of patient identification. This may involve using largely practice based registers, databases held at local authority or school level, or PCT Local Delivery Plan Healthcare Commission Indicator data. The development of a tiered model of care may also help identify appropriate levels of intervention (see additional supportive notes for more detail).
Providers should be clear that specific national guidance for the management of overweight and obesity in both adults and children can be found within ‘Care Pathway for the management of overweight and obesity’ www.dh.gov.uk/obesity as well as NICE guidance (2006) www.nice.org.uk/guidance/CG43/.
Further information about obesity and weight management to support the following service outline can be found at:
§ www.dh.gov.uk/obesity and click on ‘Useful Links’ – Department of Health
§ www.nationalobesityforum.org.uk – the National Obesity Forum
§ www.aso.org.uk – the Association for the Study of Obesity.
Providers should consider all or the majority of the following:
1. Develop a written strategy and implementation plan for service delivery which should include, as a minimum, plans and protocols for data recording, advice and provision of information, onward referral to specialists or other support programmes, integration with other professionals or organizations, and on-going training and educational opportunities for staff, and patient involvement.
2. Designate a senior clinician to have overall responsibility for health service provision.
3. Create and/or maintain an up-to-date register of patient’s BMIs (and other key measures as appropriate) and use it for on-going systematic primary care management, referral and/or treatment regimens.
Note - The additional notes section below provides further information about BMI measurement. Providers should also note the adult BMI measures in QOF and also child height and weight measures performed in schools. This may necessitate integration and information exchange with other providers such as Local Authority partners.
4. Provide an assessment of risk by measuring Blood Pressure, Fasting Blood Glucose, Fasting Lipid Profile, and Metabolic Syndrome review for those patients with a BMI of 30 or above.
5. Provide an initial clinical and lifestyle assessment, including checks on diet and physical activity levels, readiness to change, and degree of family and social support available.
6. Provide access to a regular, personalised obesity management programme offering one-to-one, group or a mixture of support or refer to a NHS or non-NHS community weight loss or physical activity programme as appropriate and according to local entry and exit guidelines.
7. Provide first line management including tailored advice, support and information to reduce calorie intake and to increase sustainable physical activity behaviours and reduce sedentary behaviours in accordance with national guidance.
8. Develop with patients a personalised management plan to include further information and advice about food labelling, healthy eating recommendations, local physical activity opportunities, goal setting and diary monitoring.
Note – for useful guidance and information on behaviour change and individual opportunities to manage
weight, visit the SIGN website www.sign.ac.uk/pdf/sign8.pdf and Patient Plus website
www.patient.co.uk/showdoc/40000874.
9. Provide drug therapy as an addition, rather than an alternative, to lifestyle intervention in accordance with national guidance and only after dietary, exercise and behavioural approaches have been started and evaluated www.nice.org.uk.
10. Refer for specialist support such as a dietician, physiotherapist, psychologist, surgical opinion, paediatrics, specialist weight management clinic, physical activity specialist or shared care.
11. Refer to a peer support group or expert patient programme www.expertpatients.nhs.uk
12. Monitoring and follow up patient goals for weight loss or no weight gain on a three monthly basis.
9. Support for Self Care / Weight management is an important element of self care, helping people take action for themselves, their children and their families to stay fit and maintain good physical and mental well being.
Providers should be in a position to identify those individuals who would benefit from additional support for self care and enable these individuals to access the four main areas of self care - Skills and Education; Information; Tools and Devices; Self Care support networks. Additional detail around support for self care can be found in a parallel Primary Care Service Framework which can be found at www.pcc.nhs.uk.
10. Location of Service / Commissioners will need to re-assure themselves that any service is provided from premises that are fit for purpose in a modern and way and address issues of service uptake, particularly in communities with poor health outcomes. Details should be included here.
11. Integrated Governance / Any commissioned service must meet all national standards of service quality and clinical governance including those set out in Standards for Better Health (updated April 2006 www.dh.gov.uk). These core and developmental standards of provision are designed to cover the full spectrum of health care as defined in the Health and Social Care (Community Health and Standards) Act 2003. The seven domains are safety, clinical and cost effectiveness, governance, patient focus, accessible and responsive care, the care environment and public health. Compliance with NICE guidance www.nice.org.uk is also required.
Clinical Governance arrangements must be proportionate to the service provided and comply with any local expectations or requirements of the commissioner.
Professional competency, education and training – All healthcare professions delivering the service will be required to demonstrate their professional eligibility, competence, and continuing professional development in order to remain up-to-date and deliver an effective service which is culturally appropriate. Staff appraisal on an annual basis and at an appropriate level will also be required. Commissioners will need to be reassured that practitioners have the required competencies at an appropriate level.
Commissioners should be satisfied that providers who promote obesity management have a planned, regular programme of education, training and support for their staff, extended team and community networks in matters related to their programme(s).
Training and educational opportunities are also available such as brief intervention or counselling skills, health eating and physical activity messages. Whilst these may be organised in-house, one example is the Carnegie Weight Management programme at Leeds Metropolitan University. For more specialised services, refer to a fully qualified dietician or appropriately qualified physical activity specialist on the Register of Exercise Professionals for example. Further information on training courses can be found at www.domuk.org/obesity_training.php
Providers should ensure safe staffing capacity at all times and staff should be able to demonstrate that they have participated in organisational mandatory and update training, for example infection control, manual handling, risk assessment as required.
Patient, public and staff safety – Providers will be required to demonstrate that evidence based clinical guidelines are being used. Providers should have in place appropriate health and safety and risk management systems and that premises are safe and young person friendly. They should also ensure that any risk assessments and significant events are both documented and audited regularly and outcomes of these implemented. Services should comply with national requirements for recording, reporting, investigation and implementation of learning from incidents. Further details can be found on the National Patient Safety Agency website www.npsa.nhs.uk.
Clinical audit and review – Providers will be required to demonstrate their coordination of and involvement in regular inter-professional and inter-agency meetings and regular clinical audit of the service interventions and outcomes such as drug therapies or well-being and behaviour changes.
Information management – Any communications strategy or provision should be coherent with and follow local policies and the Department of Health Code of Confidentiality, local child and adult protection procedures, and should outline the mechanisms to safeguard patient information when shared within an integrated service.
Patient and public involvement – Providers will be required to demonstrate active engagement with patients and local communities in developing services, self care plans or in supporting patients to utilise self care opportunities. Providers should demonstrate how systematic patient feedback is being used to shape and improve services.
Equality and human rights - Delivering good quality care will require organisations to demonstrate competence in identifying and taking action on inequality and also needing to engage with communities that have not found accessing public services easy. Undertaking Equality Impact Assessments (EQIAs) is a specific legal obligation, and conducting EQIAs and using the evidence to create a meaningful dialogue with communities (especially seldom heard from groups) is central to effective commissioning and service provision. This will create an evidence-based approach. As a minimum, core standard C7e of Standards for Better Health stipulates “healthcare organisations should enable all members of the population to access services equally and offer choice in access to services and treatment equitably”.