Background
The project was developed for those most at risk of ill health due to obesity.
The pilot was based in three GP practices, but has since been extended across Telford and Wrekin.
Following the publication of the NSF for Coronary Heart Disease, the Telford and Wrekin Primary Care Group decided to explore the issues around lifestyle change for the obese patient, for health professionals and for the funding authorities.
Local consultation showed that practices did not have the capacity to deliver the programme envisaged, and also, would not adapt as easily to the holistic nature of the work being necessarily more focussed on the medical model of care and treatment. It was therefore decided to form a peripatetic Lifestyle Change team within the Health Promotion department.
Recognition was given to the fact that by the time a patient was diagnosed as "obese" they are likely to have made many failed attempts to lose weight and might well have low confidence in their ability to make any lasting changes. To tackle this aspect, motivational interviewing, which enabled people to look forward, resolve any ambivalence they might have about change and take responsibility for change, was employed.
It was also recognised that although patients required accurate basic information about nutrition and physical activity, this could not all be provided at once-as few people actually take on board 100 per cent of information in one sitting. Any information provided also needed to be as practical, realistic and locally relevant as possible.
Essentially it was recognised that support needed to be regular, accessible and long term.
How this service improves
For every kilogram of weight lost a year after Type 2 diagnosis, there is a 3-4 month increased life expectancy. Couple this with the fact that for each kilogram increase in weight in the population the risk of developing Type 2 increases by 4.5 per cent, and this provides a solid case for promoting a model of treatment for obese patients through lifestyle change.
Service Provided
The model for motivating and supporting obese patients was based upon the well-known psychological model of behaviour change. This recognises that behaviour changes are part of an ongoing process, which in reality often involve a period of relapse.
Patients referred by their practice are offered appointments to look at their motivation and confidence levels, and their eating and exercise patterns. They are then invited to attend a weekly rolling programme of practical workshops and activities.
The GP, practice nurse, health visitor/district nurse or secondary care nurse/doctor refers patients to the programme using the referral criteria given below, but each patient must book their Lifestyle Change appointment (usually by phone). This ensures initial motivation.
People referred to the programme are first given a 45-minute session exploring motivation and confidence levels, knowledge base, skills, eating and exercise patterns, and detailed action plans at local clinic. If the person is assessed as suitable they are then offered weekly one-hour sessions on a rolling programme of workshops and activities, eg. organised walks, sessions on food portions, food and mood and cooking demonstrations, and are introduced to community based initiatives, clubs and groups.
After 12 weeks their progress is reviewed and they are offered further sessions on workshops/activities. They are reviewed again at six months and, again, offered further sessions on workshops/activities. Six-monthly reviews continue thereafter.
There is no set time limit for the continuation of support, although patients are encouraged to make use of ongoing services, clubs and support structures in their communities.
Referral criteria:
· Body Mass Index (BMI) >30
· Diabetes (stable) newly diagnosed must see a dietitian first, who can then refer if appropriate.
· Coronary heart disease
· High risk of CHD (cholesterol 5.0-6.4, triglycerides <2.3) otherwise refer to dietitian first, who can refer if appropriate.
· Awaiting surgery that requires weight loss
· Precursor/addition to prescribing of anti-obesity medication
This is a rolling programme of workshops held weekly for all assessed Lifestyle Change Clients. A wide range of subjects are covered each week that aim to inform and motivate clients with their weight loss goals. Subjects include portion control, stress and food, the importance of exercise, a short walk among others.
Accountability
Telford & Wrekin Primary Care Trust
Project Aims
Sustainable lifestyle changes that reduce the risk of CHD & Obesity
Evaluation
Out of 915 people reviewed after 12 weeks:
76% had lost weight
12% had stayed the same weight
12% had put on weight
Out of those reviewed after six months:
74% had lost weight
10% had stayed the same weight
16% had put on weight
In a sample of clients recently assessed at their 12 week review:
90% reported an increase in fruit and vegetable consumption
90% reported better portion control
100% reported they had become more physically active
65% reported that they were achieving the recommended weekly levels of moderate physical activity
Qualitative data also showed that patients were much better able to maintain their weight during periods of stress and restarted their weight loss programme sooner after a ?relapse?. Positive changes in mood and self-esteem have also been noted.
Participants' Comments:
I recently went to see my consultant and he commented on how well I am looking compared to when he saw me last year. I told him that I have far more energy now, have lost weight and that my mood is much better. When he asked me what had changed, I told him it was the Lifestyle Change Service and these workshops that were responsible for the difference in me.
It was great being able to go swimming and do some exercise with no one else around laughing at me
Resources
Workers were recruited based upon their aptitude to communicate effectively and whose interpersonal skills were exemplary. The successful applicants were then trained in nutrition, exercise and motivational interviewing. As the positions were advertised as training posts, we were able to keep to the allocated budget and had no problems with recruitment.
Based on the capacity to see 1000 new clients per year offering one assessment, regular reviews and a place on the workshop for 12 months costs a total of £113 per patient.
Learning
Although this project has had a budget enabling us to create a gold star service, it should be possible (with a bit of creativity, negotiation and recognition of overlapping organisational objectives) to adapt and deliver in other areas. Slimming Clubs, local gyms, workplaces and life-long learning enterprises amongst other organisations, all have some vested interest in lifestyle change and should not be forgotten if willingness and creativity is high, but finances low.
Sustainability
Key to the successful ongoing funding of this initiative has been the systematic explanation and reporting back of the project?s predicted and monitored outcomes as related to the PCT's key priorities. (eg. the prevention targets set within the coronary heart disease NSF, and the promotion of more effective prescribing of medication to reduce prescribing costs).