Appraisal of the NHS weight management service

Published: 2020-07-20 09:40:10
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This paper is a critical assessment of the Measure by Step, weight direction service offered by NHS Western Cheshire. The service is a combined dietary and physical activity programme offered to occupants of Western Cheshire with a BMI of 30 or supra. The programme lasts for 6 months with the first 12 hebdomads dwelling of hebdomadal contact Sessionss of dietetic instruction and physical activity taste tester Sessionss followed by biweekly follow-up Sessionss. Entry into the programme is by wellness professional referral merely, with the bulk of referrals coming via primary attention, either GP or Practice / District Nurse.
The purpose of this paper is to reexamine the administration and construction of the service and reflect on possible alterations or betterments that might be required to guarantee the service meets its aims within the resources available to the service, and guarantee long term sustainability for both service users and suppliers.
The range of this paper is limited to a reappraisal of the Measure by Step service within NHS Western Cheshire. The reappraisal will non look at how the service tantrums in with other national, regional or local weight direction services or other wellness betterment services offered by NHS Western Cheshire. However, factors, such as national, regional and local policies and schemes, which have influenced the development of the service will be reviewed.
The chief aim of this paper is to critically measure the service with specific focal point on the agreements for ;
Decision devising and answerability.
Sustainability of relationships with cardinal spouses, including wellness professionals, public, private and voluntary sector service suppliers, and service users.
Performance direction of the service, including quality confidence, resource direction, and direction information.
Context
Overweight and fleshiness can be defined as unnatural or inordinate fat accretion that may impair wellness ( 1 ) . In grownups, fleshiness is associated with an increased hazard of diseases that are a major cause of morbidity and mortality, notably type 2 diabetes, coronary bosom disease ( CHD ) , high blood pressure, assorted malignant neoplastic diseases and degenerative arthritis ( 2 ) .Classification of people as corpulence or corpulent is normally based on an person ‘s organic structure mass index ( BMI ) ( 3 ) , and there is good grounds to bespeak that BMI is a valid and dependable step for placing grownups with an increased hazard of morbidity and mortality due to extra weight ( 4 ) . The prevalence of corpulence and fleshiness is increasing in both grownup and kid populations throughout the universe and fleshiness bar has become an international public wellness precedence ( 5 ) . The World Health Organisation ( WHO ) has projected that worldwide, by 2015, about 2.3 billion grownups will be fleshy and over 700 million will be corpulent ( 1 ) . From a United Kingdom position, the proportion of grownups who were categorised as corpulent ( BMI 30kg/m2 or over ) increased from 13 % of work forces in 1993 to 24 % in 2008 and from 16 % of adult females in 1993 to 25 % in 2008 ( 6 ) . By 2050 the prevalence of fleshiness is predicted to be 60 % of grownup work forces, 50 % of big adult females and 25 % of kids ( 7 ) .
The UK Government highlighted fleshiness as one of the greatest public wellness challenges of our clip ( 8 ) and challenged authorities and the NHS to work together to hold the lifting tendency. The National Institute for Health and Clinical Excellence ( NICE ) produced guidelines on the bar, designation, appraisal and direction of corpulence and fleshiness in grownups and kids ( 9 ) . This was followed by the authorities denoting a long-run aspiration to change by reversal the lifting tide of fleshiness and corpulence in the population. As portion of this, a Public Service Agreement ( PSA12 ) to better the wellness and well-being of kids and immature people was established ( 10 ) . The PSA purposes to cut down the proportion of corpulent and fleshy kids to 2000 degrees by 2020. Following on from this, the cross-government scheme, Healthy Weight, Healthy Lives: A Cross Government Strategy for England ( 11 ) set out a scheme to present the PSA aspiration.
From a local position, in the NHS Western Cheshire Primary Care Trust ( PCT ) country, the sum estimated figure of grownups ( aged 16 old ages and supra ) who are corpulent is 49,842 ( 23 % ) , with a farther 79,295 grownups ( 37 % ) sing increased wellness hazard due to raised waist perimeter ( 12 ) . Harmonizing to General Practitioner ( GP ) records of BMI, the prevalence of fleshiness is highest in patients from the most disadvantaged 40 % of countries and among those aged 40-64 old ages, with over half of patients recorded as being corpulent in this age group ( 12 ) .
As portion of its response to lifting degrees of fleshiness, in 2008 NHS Western Cheshire PCT commissioned a community weight direction programme, Step by Step, from the Trust ‘s specializer Health Promotion Service. This free, referral-based programme is targeted at persons at high hazard of developing negative wellness results as a effect of fleshiness, as indicated by a BMI of a‰? 35kg/m2 or 30-34.9kg/m2 and at least one hazard factor from a specified list, including Type 2 Diabetes, Hypertension and Cardiovascular Disease. Measure by Step is delivered in a assortment of community locales across Chester and Ellesmere Port. The programme is of 6 months continuance and comprises two phases:
a three month period of 12 hebdomadal group Sessionss on healthy feeding, physical activity and behavior alteration ;
a three month period of support and followup with group Sessionss scheduled at biweekly intervals.
Structure
The Measure by Step service has a perpendicular, functional direction construction ( 13 ) ( see fig. 1 ) with the service director describing straight to the Public Health Improvement Manager, although the service is commissioned by, and, as such, is responsible to the Public Health Improvement Lead for Healthy Weight for service bringing and quality. The Public Health Improvement Lead besides reports to the Public Health Improvement Manager. It is suggested that holding two ironss of bid, as in this instance, can be a major failing of the direction construction and lead to power battles ( 13 ) . In this instance, the Public Health Improvement Lead for Healthy Weight, as the service commissioner, has authorization over service bringing and aims while the Public Health Improvement Manager is responsible for Human Resource affairs. All three parties claim the construction does non impact the running of the service because there are clear lines of limit between duties and authorization.
Both the service director and helper are dietitians with a separate physical activity lead. The service director has no formal direction making and, although has some experience of running similar healthy weight programmes elsewhere, may non hold the necessary accomplishments to negociate for more, or better resources for the programme, if needed, and, because of the split direction construction, may non cognize who to negociate with. Hunter argues that those engaged in public wellness direction have non by and large been equipped with the needed direction accomplishments in order to back up the instance for public wellness investing and to guarantee that agreed programs and proposals are implemented ( 14 ) . The service besides employs a farther three lifestyle advisors, on a portion clip footing, who assist with the bringing of both nutritionary and activity Sessionss, and a service decision maker, who deals with all referrals and other service disposal responsibilities. All dietary/theory Sessionss provided by the service are delivered chiefly by the lead dietitian, although the service director on occasion provides some of these Sessionss. It is suggested that the functional direction construction employed in this service might be slow to react to client demands ( 13 ) , because the service director on occasion delivers Sessionss it serves to keep a direct contact between the director and service users and, as such, helps to guarantee the service is better able to react to client demands. However this may besides take to conflict between service bringing and direction ideals ( 15 ) .
The Physical Activity Lead co-ordinates bringing of the physical activity Sessionss, which are by and large delivered by the three parttime staff, the service besides employs a figure of external suppliers on a sessional footing to supply extra physical activity Sessionss. There may besides be a possible to associate in with other voluntary sector suppliers to present activity Sessionss, but this has non been explored by the service. The dietary/theory Sessionss are provided on a hebdomadal footing as portion of a structured, 12 hebdomad weight direction programme and all service users are expected to go to all Sessionss. Whereas attending at the scope of hebdomadal physical activity Sessionss that are besides provided is optional, although service users are encouraged to go to as many Sessionss as they can. Increased physical activity is of import in attempts to lose weight because it increases energy outgo and plays an built-in function in weight care and besides reduces the hazard of bosom disease more than that achieved by weight loss entirely ( 16 ) , hence optional attending for activity Sessionss may cut down the effectivity of the service.
The weight direction service has a little squad of staff but this need non impact the quality of services provided, as Wanless suggested while the specialist public wellness work force is an indispensable constituent of the public wellness map, it is little and, to accomplish the greatest impact, must prosecute with and tackle the resources of other subscribers, across all sectors ” ( 17 ) . The service presently engages good with primary health care suppliers, and many of the local GP patterns refer into the service, nevertheless, there is still a demand for wider battle with other stakeholders, including public, private and voluntary sector administrations, every bit good as other NHS sections, such as physical therapy and coronary care/cardiac rehabilitation, for illustration, peculiarly if a self-referral tract is introduced, as planned.
Administration is defined as the construction through which the aims of an administration are set and the agencies of achieving these aims and monitoring public presentation are determined ” ( 18 ) ( See fig. 2 for Healthy Weight administration construction ) .
Figure 2. Healthy Weight Group Governance StructureThe Health and Wellbeing Partnership Board is a sub-group of the West Cheshire Together, Local Strategic Partnership, a web of multi-agency partnerships through which spouses from across the populace, private, community, voluntary and faith sectors come together and work collaboratively to undertake local jobs, better local quality of life and present precedence results for local people ( 19 ) . The way for the service comes from the Healthy Weight Strategic Group, a undertaking and finish sub-group of the Health and Wellbeing Partnership Board, who, with the support of the Public Health Improvement Lead for Healthy Weight, guarantee that the service incorporates national counsel into local pattern. It does this through the development of a local bringing program for healthy weight, based upon the Western Cheshire Healthy Weight Strategic Plan, which is underpinned by national and regional schemes and counsel, such as NICE Public Health Guidance ( 9 ) and national schemes ( 11 ) . The Strategic Group Members are responsible for guaranting the program is delivered to timescale and actions achieved are supplying the expected results. The service director, through the Public Health Improvement Lead for Healthy Weight, is accountable to the Healthy Weight Strategic Group. This construction provides another possible cause for struggle because the Public Health Improvement Lead besides has two direction ironss of bid, with duty to the strategic group for bringing of the strategic program aims, but a corporate duty to NHS Western Cheshire, through the Public Health Improvement Manager, for keeping fiscal control of the service. However, as the Health and Wellbeing Partnership Board is chaired by the Director of Public Health, who besides has ultimate duty for the Health Improvement map within the PCT, it could be said that the aims are one and the same. It does nevertheless exemplify the complex administration construction that presently exists for the weight direction service.
Quality
Quality is frequently defined as fittingness for intent ” ( 20 ) but, because the intent of a merchandise or service is defined non merely by the service supplier but besides by the user, fittingness for intent is a fluid construct and will probably change from individual to individual. For this ground quality must be expressed in footings of both fittingness for intent and as run intoing the demands of the service user ( 21 ) . For the intent of this reappraisal the proviso of quality services will be informed by Maxwell ‘s dimensions for quality wellness attention proviso ( 22 ) and includes ; Access to services ; Relevance to necessitate ; Effectiveness ; Equity ; Social Acceptability ; and Efficiency and Economy. Responsibility for guaranting the quality of the weight direction service rests with the service director, who reports to the Public Health Improvement Lead for Healthy Weight.
Entree to the service – is presently merely by referral from a healthcare professional, this means that the service is possibly non as widely accessible as it might be. A possible country of concern is the differing point of views of wellness professionals ( 21 ) who, it might be said, would prefer to mention patients to a medical intercession, such as bariatric surgery, in favor of lifestyle advice and exercising. The service director and Public Health Improvement Lead are presently looking at the possibility of inciting a self-referral tract, which would increase entree to the service. However this would put them in direct competition with commercial weight loss groups, such as Weight Watchers and Slimming World, and it is dubious whether the service will hold the necessary resources to vie in this market topographic point, due to cost and the ability to proviside of out of hours services.
The Sessionss offered by the service are by and large provided Monday to Friday, 9:00am to 5:00pm, although some Sessionss provided outside of these hours. This is under reappraisal by the director and Health Improvement Lead with a position to bettering handiness, which will be indispensable if the service is to vie against commercial administrations, who by and large offer out of hours service proviso. Evaluation is besides taking topographic point around other methods of bettering service handiness, including clients being able to take locales and get down day of the months that best suit them, but this may intend that some Sessionss have lower than ideal Numberss while others will hold waiting lists, taking to prolonged holds from registration to programme start. Therefore it may besides be necessary to hold a rolled programme in certain, high involvement locales to understate waiting times.
Relevance to necessitate – Public wellness traditionally uses epidemiological informations to find the health care needs of a population, whether that be nationally, regionally or locally ( 23 ) . The grownup weight direction service was borne out of the NHS Western Cheshire Joint Strategic Needs Assessment ( 12 ) and grounds shows that a service supplying both dietetic advice and structured physical activity Sessionss can be an effectual tool to assist grownups cut down their weight ( 24 ) . Whilst it might be more appropriate for the physical activity Sessionss to besides be a compulsory portion of the programme, as stated above, the current handiness of Sessionss agencies this is improbable to be executable. However, as more exercising Sessionss become available outside the current Monday to Friday, 9:00am to 5:00pm clip slot, so necessitating participants to go to regular exercising Sessionss is likely to be more accomplishable.
Effectiveness – The programme records all informations required by the service specification every bit good as extra informations recommended by the National Obesity Observatory ( 25 ) . This includes baseline, 12 hebdomad and 6 months follow-up informations, there is besides a demand for the service to roll up 12 month follow-up informations, to demo long term sustainability of lifestyle behavior alteration, but this demand was merely late introduced, so information has yet to be collected, and methods of informations aggregation have yet to be finalised. Key marks for the programme are as follows: –
Average waiting clip from referral to first session attended to be no more than 6 hebdomads.
90 % of service users offered a first assignment within 6 hebdomads of referral.
75 % of service users accessing a class within 6 hebdomads of referral.
65 % of service users entering successful weight loss after 6 months.
30 % of service users entering at least 5 % weight loss from baseline after 6 months.
Additionally at least 30 % of service users should be male and at least 50 % should be from countries of want, as defined by quintiles 1 and 2 of the indices of multiple want. The service is besides required to enter life style informations at baseline, terminal of class ( 6 months ) and at 12 month follow-up, this will include informations to step ; Quality of Life, Activity Levels, Healthy Eating and Self-esteem and emotional wellbeing. This is besides a new demand for the service validated methods of capturing this information or presently being investigated.
The service director holds quarterly review meetings with the Public Health Improvement Lead, where countries of concern, or short autumn in end products can be identified and appropriate stairss taken to retrieve the state of affairs.
Equity – All services are delivered harmonizing to demand and bringing is by and large seen as being just and just. However, as entry to the programme is presently limited to wellness professional referral merely, it could be said that the service is non genuinely just, although the possible debut of a self-referral tract, as mentioned above, will let more just entree, although this in itself is likely to raise more issues. Because the service specification sets marks for a per centum of service users to be male, or from a deprived community, could besides be construed as non being just. However, as informations from the local demands appraisal ( 12 ) indicate these populations are more in demand of the service, it might besides be construed that by puting these marks it serves to implement a more just service bringing.
Acceptability – All service users are required to finish a programme satisfaction study at the terminal of their 12 hebdomad programme and this information is fed back to measure service acceptableness. Currently about 82 % of service users are satisfied with the service provided. However this figure is likely to be biased as merely service users who complete the 12 hebdomad programme presently complete the satisfaction study. A remark card system will be introduced in the new twelvemonth, which will hopefully promote feedback from more service users, including those who do non finish the 12 hebdomad programme. However, possibly a more appropriate method would be to reach all those neglecting to finish the programme to transport out rating, although the cost deductions for this would necessitate to be reviewed.
Efficiency and Economy – Efficiency is defined as supplying quality service at minimal cost within a system that is crystalline and with managerial answerability for service outgo ( 21 ) . Furthermore it is suggested that in systems where both funding and bringing of attention is a public duty, attempts to separate the functions of wellness attention remunerators and suppliers, so as to let markets to map and generate efficiencies from competition, have proved by and large effectual ” ( 18 ) . This service is both commissioned and funded through the Public Health budget. Although the service is presently provided from within the public wellness squad, under current restructuring of the PCT, all supplier services are being transferred to another NHS trust, with the current PCT going the commissioner of services merely. This will function to divide these two maps and may take to a more efficient service, although it remains to be seen whether this will be the instance as grounds of increased efficiency as a consequence of similar reforms is ambiguous ( 26 ) . It besides remains to be seen whether the service will be able to vie in an unfastened market state of affairs against commercial competition if the proposed self-referral tract is introduced.
Pull offing Change
The service has been good at reacting to rating and presenting alteration, albeit, within the limited resources at its disposal. A recent rating of the service ( 27 ) made the undermentioned recommendations ;
Change programme from 12 months to 6 months
Change nutritionary Sessionss from hebdomadal to biweekly but maintain activity Sessionss on a hebdomadal footing.
Use embassadors from old Sessionss to actuate participants
Advice brochure to be sent to participants after referral and before get downing Sessionss.
Contact clients who miss 2 Sessionss to promote attending.
Mail shooting sent to all participants at 4 hebdomads and 9 hebdomads to promote attending.
To day of the month the first two of these recommendations have been implemented, an advice brochure is presently being developed, to be available in the new twelvemonth and the usage of embassadors is besides presently being investigated. Contact with nonchurchgoing clients is being reviewed, as is the usage of mail shootings to all participants at cardinal points in the programme, but the service may non be able to implement these options because of limited resources, or at least may hold to restrict contact to electronic mail or by text message, which attract a limited response.
With the current re-organisation of the NHS, following the latest authorities white documents ( 28, 29 ) , all supplier services within the current construction are being transferred to a sister trust, Cheshire and Wirral Partnership Trust. This alteration will do the administration construction less complex and will divide the duty for fiscal control and bringing of service results and aims, which should function to heighten the efficiency of the service ( 18 ) .
Decision
The service design is presently based upon clinical demands and, with a wellness professional referral tract entirely, is equal for the demands of its current stakeholders. However the planned debut of a self-referral tract will open the service up to commercial competition in the signifier of national, commercial slimming administrations. Additionally one of the prospective referral paths will be through pharmaceuticss, many of whom besides market other weight direction merchandises, frequently including their ain merchandise lines, such as slimming shingles for illustration. Therefore whether this development will be successful and whether a local, public funded service can vie against national, commercial competition remains to be seen. Another concern, if the development is successful, will be the ability of the service to get by with the possible increased demand of the self-referral tract, in peculiar the demand for chiefly out of hours service proviso.
The current service is good managed and appears to get by good with the altering bringing demands imposed upon it and the complex administration construction that it operates within. These are proving times for wellness betterment services, with the current public wellness map reassigning to local authorization control and the transportation of bing supplier services to a new NHS trust. The little, but dedicated squad that deliver this programme has coped good with the alterations imposed upon them by an germinating service specification in the yesteryear. The following few months will be a hard clip for all involved in the service and it will necessitate all of the accomplishments of the service director and Health Improvement Lead to steer the service through this period of alteration, to emerge as an effectual and sustainable weight direction service, able to run and vie in a commercial market topographic point.

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