Increasing levels of obesity are a global problem, with obesity rates tripling since 1975. But the UK ranks as one of the worst countries in Europe. Some 26% of adults in England are obese and a further 38% are overweight. This is putting an increasing strain on the NHS.
There were just over one million hospital admissions in 2019/20 where obesity was recorded as the primary or secondary diagnosis – up 17% on 2018/19. During the pandemic, there was a major increase in obesity in children. And there is recognition that obesity is more prevalent among those living in more deprived areas.
To help tackle some of these issues, the NHS long-term plan introduced a digital weight management service targeted at people
with a body mass index above 30 and with a diagnosis of type 2 diabetes or hypertension.
As a tier 2 service – which is the next step up from universally available support – weight management services would typically be commissioned by local authorities. However, this new targeted programme has been specifically set up to run alongside existing council-provided services.
The digital angle was born out of Covid and the need to minimise face-to-face contacts, but it has proved to have other benefits – particularly in the way it has enabled the collection of data to demonstrate results and to support the development of the service.
Unlike locally run but nationally supported services, such as those for alcohol dependency and smoking cessation, the weight management service is completely centrally funded.
Access is via a GP referral and has been automated as much as possible – it only takes six clicks from an initial consultation to sending the referral. There are incentives for GPs to refer to the service. The digital programme is one of four weight management options, referral to which triggers an £11.50 payment as part of a £20m funded enhanced service scheme.
This has helped to embed the programme, which is now in its second full year, with nearly 70% of general practices having made at least five referrals to the programme.
There is an initial triaging step, which checks eligibility, and then assigns people to one of three levels of support, all delivered over a
12-week period via phone app or web browser.
Level 1 is a self-guided programme, with diet and lifestyle advice, all delivered via an app. Level 2 adds in 50 minutes of one-to-one coaching with a dietician or similar practitioner. Level 3 increases this to 100 minutes. There are choices within each level so that participants can select the programme that most suits them.
In fact, NHS England has 10 contracts with six separate providers giving participants a choice of at least three different providers at each level. Payment by NHS England to providers is based on participants entering their weight on three different specified occasions. It is quite an aggressive payment structure. Participants are not obliged to enter their weight if they do not want to, but they cannot be dropped from the programme, so it pushes the companies to develop content that properly engages with users.
The data input is regarded as really important for the programme as it helps to prove its cost-effectiveness.
But it also provides real-time data on how the programme is progressing – not the usual data lag of several months that is often a feature of NHS reporting. This can provide insight into the impact over time – and if people remain connected to the app after concluding the 12 weeks, it can even show the lasting impact of the programme.
The programme started in July 2021 and has taken some 220,000 GP referrals in that time – and the numbers are increasing. There were thoughts that the ceiling of what general practice was able to refer had been reached last year. But it is understood that the first few months of this year have proved that to be completely wrong – so there is no firm idea yet of what a business-as-usual number would be.
Success is measured in terms of retention and weight loss. Completion is deemed to be participating in seven out of the 12 weeks and is hovering around the 50% to 55% mark – which is seen as good compared with other weight management programmes.
The programme obviously also measures weight change and is currently reporting an average weight loss of 3.9kg for those completing the programme. Among non-completers, the weight loss is about 2.3kg. So people on the programme are losing weight on average, with more weight lost for each additional week participants engage.
The data enables the programme to see the impact by age or deprivation and can also show which providers work best with people from different ethnic groups. The data will all feed into the national obesity audit, which together with data from other programmes and sources will start to paint a much more granular picture about obesity levels across the country and the approaches that work best in supporting people to manage their weight better.
The data is vital. Justification of the programme is straightforward. Obesity is a modifiable risk factor that can reduce downstream cases of type 2 diabetes and hypertension. And the programme is delivering good outcomes in terms of weight loss. But the progamme’s leaders are keen to understand the long-term impact and hope to run the programme for at least another three years to get a critical volume of patients through and fine tune how it works. Crucially, the programme wants to explore whether it is supporting real lifestyle change. The national obesity audit will be key to this understanding.
There are lots of short-term benefits – people feel more empowered and in control of their health, with fewer trips to the GP. Although evidence of the longer term benefits will take a while, the programme’s leaders think this will be time – and money – well spent.
Improvisation develops confidence and the skills of listening and building on colleagues’ ideas.
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