Shropshire Public Health Operating Procedure...is pregnant with a BMI ≥ 30 at ante-natal booking appointment is aged 16 years or above Adults falling within the overweight BMI classification

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Shropshire Public Health Operating Procedure

Weight Management Services

October 2016

This document provides a framework for the delivery of weight management services for children and adults in Shropshire County. Guidance relating to referrals and treatment are based on NICE guidelines. All providers engaged in delivery of weight management services in Shropshire County are required to operate to this procedural framework. Any changes to this Operating Procedure must be agreed with Help2Change. Help2Change retains the right to amend and update this Operating Procedure in light of local and national evidence of best practice. For all queries relating to this Operating Procedure, please contact Help2Change on 01743 454910.

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Table of Contents

INTRODUCTION .............................................................................................................. 3

WEIGHT MANAGEMENT SERVICE DESCRIPTION: ...................................................... 3

Referral criteria .................................................................................................................. 4

Children & Families (Fit Families) Service ......................................................................... 4

Adult (Help2Slim) Service .................................................................................................. 4

Referral route .................................................................................................................... 5

Response time and prioritisation ........................................................................................ 5

Discharge criteria. ............................................................................................................. 6

Outline service delivery model: …….……………………........……………………...………....6

Children & Families (Fit Families) Service ......................................................................... 7

Adult (Help2Slim) Service…………………………………………………………………………7

Training requirements ........................................................................................................ 7

Data requirements ............................................................................................................. 8

Equipment use .................................................................................................................. 8

Pharmacotherapy .............................................................................................................. 9

Use of Very Low Calorie Diet (VLCD) ................................................................................ 9

Delivery location and days/hours of operation ................................................................... 9

Service outcomes .............................................................................................................. 9

APPENDICES

Appendix 1 - Weight Management Service delivery options ….....…………………....…...10

Appendix 2 - Behaviour change support in Weight Management .…………………....…...11

Appendix 3 - Prescribing Protocol for anti-obesity medication within Help2slim …………12

Appendix 4 - Outline Children & Families (Fit Families) Service Structure….………...…..13

Appendix 5 - Outline Adult (Help2Slim) Service Structure….………………..........…...…..14

Appendix 6 – Service User Satisfaction Survey Questionnaire ………………………....…15

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INTRODUCTION

This framework is intended to provide guidance and consistency in the delivery of weight

management services in Shropshire County. It includes delivery of child and adult (including

maternal) weight management services. These are either developing or relatively new

services.

Obesity poses a major threat to population health and is placing an increasing burden on

health and social care services. A quarter of Shropshire adults is clinically obese, and two

thirds overweight. Rates of obesity have trebled in the past 30 years and the trend continues

upwards. Over one in five women in Shropshire County enters pregnancy obese and. Obesity

is also occurring at a younger age, with one in nine children in Shropshire County obese by

the time they enter reception class at primary school. This figure increases to one in six by

age 10-11 years.

Evidence-based weight management services are effective in both cost and clinical terms.

Weight loss improves obesity-related comorbidity and can have a mortality benefit. Evidence

base is summarised in:

National Institute for Clinical Excellence (NICE) Clinical Guideline 43 - Obesity:

Guidance on the prevention, identification, assessment and management of over-

weight and obesity in adults and children (Dec. 2006)

https://www.nice.org.uk/guidance/cg43/resources/guidance-obesity-pdf

NICE Clinical Guideline 189 (Nov.2014)

https://www.nice.org.uk/guidance/cg189/resources/guidance-obesity-identification-

assessment-and-management-of-overweight-and-obesity-in-children-young-people-

and-adults-pdf

NICE Guideline NG 7 - Maintaining a healthy weight & preventing excess weight gain

among children and adults (March 2015)

https://www.nice.org.uk/guidance/ng7/resources/preventing-excess-weight-gain-

51045164485

Obesity is also a key driver of health inequalities. Obesity prevalence is highest in deprived communities and reducing it among these communities will help reduce health inequalities.

WEIGHT MANAGEMENT SERVICE DESCRIPTION

The purpose of weight management services is to provide evidence-based treatment and

behavioural support to service users to achieve and maintain a healthy weight. The delivery

of the weight management services will reduce levels of weight-related disease, disability,

premature death, and health inequality in Shropshire’s child and adult populations.

Services are offered free at point of use supporting individual behaviour change to target

clinically beneficial weight change and are delivered in-line with current best practice

recommendations for weight management services issued by the National Institute for Health

and Care Excellence (NICE), the Department of Health (DH) and the Service Delivery Options

outlined in Appendix 1. Core service structure is described in Appendix 4-6 however, a flexible

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approach is expected in order to maximise service outcomes. The stated fixed measurement

points must be face to face appointments, however, the suggested style, duration and timing

of all other appointments can be modified as necessary within the stated time threshold.

All service user weight changes must be assessed face-to-face for outcome reporting. Self-

reported weight status is not permitted in respect of the stated fixed measurement

appointments.

Promotion of self-care prior to formal discharge from the service is expected in order to support

maintenance of lifestyle change.

The objectives are to provide weight management services that:

are equitably accessible to eligible populations

support service users to achieve and maintain a healthy weight

offer the most effective, evidence-based treatments and support available

achieve high levels of Service User satisfaction

Best practice in delivery of weight management services for children, pregnant and non-

pregnant adults is continually developing. Accordingly, this framework reflects current delivery

models and, consistent with emerging evidence, is subject to review.

Referral criteria An individual’s eligibility should be checked prior to formal entry into the Service. Formal entry includes completion of an initial assessment to confirm eligibility, agreement to participate and completion of a weight management baseline assessment.

Individuals who do not meet the stated eligibility criteria below are not eligible to access the

service unless locally agreed between Shropdoc and Help2Change . If there are queries or

concerns about the suitability of a referred individual to receive weight management support,

agreement should be sought from Help2Change before refusing to provide the service.

Children & Families (Fit Families) Service

In order to be eligible for the service, check that the Service User:

is resident in Shropshire &/or registered with GP in Shropshire;

would like to receive weight management support;

is accompanied by a parent/carer during weight management support

is not receiving weight management support from another Provider;

has a BMI ≥ 98th centile (Tier 2) or BMI ≥ 99.6th centile (Tier 2b)

is aged 5-15 years

Adult (Help2Slim) Service

Help2Slim is part of a local integrated adult obesity care pathway and includes the option of

enhanced support (Tier 2b). In line with current NICE guidance, Tier 2b eligible service users

will have access to additional psychological support as appropriate. Provision of a Tier 3

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medical support service is being considered by Shropshire’s Clinical Commissioning

Consortium (CCG). Once established, service users accessing the Help2Slim service with

very high BMI or complex comorbidity may at clinical discretion be referred into Tier 3.

In order to be eligible for the Help2Slim service, check that the Service User:

is resident in Shropshire &/or registered with GP in Shropshire;

would like to receive weight management support;

is not receiving weight management support from another Provider;

has a BMI ≥ 30 or BMI ≥ 27 with comorbidity (Tier 2);

has a BMI ≥ 40 ≤ 50 or BMI ≥ 35 with weight related comorbidity (Tier 2b);

is pregnant with a BMI ≥ 30 at ante-natal booking appointment

is aged 16 years or above Adults falling within the overweight BMI classification (BMI 25 – 29.9) may be sign-posted to

the Public Health register of weight management providers, available at

www.healthyshropshire.gov.uk

Where a service user meets all other eligibility criteria but is not registered with a Shropshire County GP, has no fixed abode or is outside the eligible age threshold for the service, please seek prior approval from Help2Change to provide weight management support. The provider is expected to support service users from the existing weight management

service who are currently receiving support to achieve a healthy weight.

Referral route

There are three methods by which individuals can access the service:

direct referral - by a healthcare professional such as a GP, practice nurse, midwife, community nurse or hospital consultant

self-referral – individuals can access the service directly in response to general information and publicity about available services

recruitment – service users can be actively recruited into the service

Service user consent must be obtained including consent to receiving weight management support, sharing of Service user details with and being contacted by other organisations directly related to service provision (Shropdoc and Help2Change).

Exclusion criteria Individuals who do not meet the eligibility criteria and are not eligible to access the service.

If you have concerns about the suitability of a Service User that has been referred to the service, please seek agreement from Help2Change before refusing to provide the service.

Response time and prioritisation Service users must be contacted within 48 hours of receipt of enquiry/referral and offered a

weight management appointment within 2 weeks of first contact.

A local rate contact telephone number will be provided to service users via the Single Point of Access (SPA) commissioned from Shropdoc by Help2Change. This must be appropriately staffed or regularly checked so that Service Users are not waiting for long periods for a

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response. Weight management advisors may need to be in telephone contact with the service user and will need regular access to either mobile or landline telephones.

Many service users find achieving and maintaining a healthy weight challenging. The weight management advisor should use discretion and professional judgement when considering whether an individual is ready to receive support. Where a decision is made that weight management support is inappropriate at that time, the individual should be provided with weight management information and if appropriate invited to re-enter at a later stage. Service Users can be recruited up to 3 times during a 12 month period, after which approval for support must be sought from Help2Change.

Discharge Criteria

Service users who fail to attend weight management support sessions (where insufficient reason given) will be discharged after 3 failed contacts and will be notified accordingly.

Service users will be discharged from the weight management service when one of the following occurs:

referred Service User is found not to be eligible for the service (unless locally

agreed between Shropdoc and Help2Change)

Service User completes the weight management programme and achieves a

healthy weight

Service user fails to achieve weight change at 3 month measurement point

unless sufficient reason given. Continuation is at the clinical discretion of the

service provider. Reasons given may be reviewed with Help2Change as part

of regular contract review meetings.

Service User informs the service provider that he/she no longer wishes to

receive the service

The Provider attempts to contact Service User on 3 separate occasions but

fails to make contact with the Service User

Third party referrers should be informed of the reason for discharge and service outcome.

Where appropriate, Service Users should be supported with information about their weight

management and other lifestyle-risk issues to promote self-care, support lifestyle change prior

to formal discharge from the Service.

All service users, including those lost to follow up, must be recorded on the EMIS Help2Slim

Template.

Outline service delivery model

Weight management services are time-limited interventions to support people who are

overweight or obese to achieve and maintain a healthy weight. Core elements of the weight

management service include the provision of behavioural change support to a large number of

eligible individuals, working closely with all GP practices in Shropshire County.

Service delivery should be consistent with the following framework:

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service User referred or recruited into the service

service User’s eligibility checked prior to formal entry into service

service user’s consent received with regard to receiving weight management support

and sharing of Service user details with Shropdoc and Help2Change

weight management baseline assessment completed

target weight change agreed and recorded (≥5% BMI)

service User receives behavioural change support (Appendix 2) from the

Provider

Services User’s weight status checked at stated intervals (Appendix 4-6)

All appointments should be scheduled when Service User is booked into weight management support All intervention should be spread across a number of sessions and the total contact should in line with the times specified in the tables listed below. Appendix 4-6

Children & Families (Fit Families) Service

Adult (Help2Slim) Service

8 hours (from baseline to 3 months); and

6 hours (from 3 months to 6 months)

inclusive of 15 minute Follow-up contact at

12 months

1.5 hours (from baseline to 4 weeks); and

1.5 hours (from 4 weeks to 3 months); and

1.5 hours (from 3 months to 6 months)

15 minute Follow-up appointment at 12

months

The above will ensure effective monitoring, Service User compliance and where appropriate and clinically advised access to anti-obesity medication.

Weight management advisers should show empathy for their Service User and adopt a motivational approach. Service User confidentiality should be respected at all times.

Training requirements

Interventions must be delivered by a weight management advisor who has received training that meets current NICE guidance for delivery of weight management services to children and adults. All advisors delivering weight management interventions must attend and complete the following Weight Management Training (provided and/or facilitated by Help2Change) before supporting any service users in weight management:

Face to face and group behaviour change support for pregnant and non-pregnant

adults

Face to face and group behaviour change support for children & young people

Other specialist training modules will be made available and should be completed as developed

Following training, all weight management advisors should receive the following support:

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observe an experienced practitioner to deliver behaviour change support to a number

of service users at various points in their weight management programme. NB.

Experienced practitioner is defined as someone ,in agreement with Help2Change,

who is confident and competent in supporting service users and is involved in current

practice;

be observed by an experienced practitioner;

receive regular supervision;

attend to their continuing professional development;

support sufficient Service Users (minimum 20/year) to maintain their core knowledge,

skills and competency in weight management

Rolling groups or drop-ins should be delivered or supervised by experienced Advisors with sufficient expertise to support service users at different stages of weight management process simultaneously.

The provider will deliver to Making Ever Contact Count (MECC) principles, ensuring staff have the appropriate skills and knowledge to give brief opportunistic advice to service users as appropriate, and support them to adopt healthy lifestyles. For information on delivering or advising on other lifestyle services please refer to the Standard operating procedures for Stop Smoking service, Physical Activity or NHS Health Check.

Data requirements

All data must be recorded in full using agreed EMIS Web template provided by Shropdoc to ensure accurate read coding and data recording. All data must be auditable and payment is conditional on receipt of accurate and full data reports for all service users formally entered into the service. Those individuals declining referral should also be recorded within the service EMIS template.

All Service Users must be provided with a service user satisfaction survey questionnaire (Appendix 8) within 4 weeks of key outcome dates i.e. 3 months and 6 months and discharge as per outcome reporting (available on the EMIS template). Paper copies can be obtained from Help2Change and should be returned to Help2Change on a quarterly basis.

Service User records must be securely stored.

Equipment use

Equipment necessary for the delivery of the weight management service, as detailed below, will be provided by and remain the property of Help2Change:

obesity scales capable of weighing a minimum of 200kg and approved under EC Directive 90/384 EEC

Height measure

selection of weight management resources and support aids

All equipment should be fully functional, used regularly, CE marked, validated, maintained and recalibrated according to the manufacturer’s instructions.

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Recalibration of equipment is the responsibility of the provider. All equipment checks and maintenance should be in line with manufacturer guidelines and should be documented and auditable. Local service awareness initiatives should be agreed with Help2Change and be integrated with local, regional and national campaigns, using locally branded materials to help smokers identify with local support services and thereby promote self-referrals. Additional promotional resources and support may be provided by Help2Change on request.

Pharmacotherapy

Pharmacotherapy refers to the provision of pharmaceutical products, medicines or medicaments. The only anti-obesity medication currently approved by NICE is orlistat (Xenical®). Prescribing of anti-obesity medication remains the responsibility of the Service User’s GP, in line with current NICE Guidance. The provider is expected to liaise with the Help2Change Clinical Lead where appropriate and to have regard to the local Prescribing Protocol for use of Orlistat within the Help2Slim weight management service (Appendix 3).

Use of Very Low Calorie Diet (VLCD)

VLCD may, where clinically advised, be used within Help2slim Tier 2b support. Use of VLCD,

including its medical supervision, should be in line with current NICE Guidance (summarised

in Appendix 7).

Delivery location and days/hours of operation

The service must be readily accessible and suitable for all eligible Service Users. The opening times of the service can be determined by the Provider and will respond to service user demand for out of hours services.

Service outcomes

The following quality service outcome indicators should be met:

Adult (Help2Slim) Service

≥35% service users achieving ≥5% weight loss at 3 months

≥50% service users achieving ≥5% weight loss at 3 months who have maintained ≥5% weight loss at 6 months

at least 90% of service users responding to the satisfaction survey must report that they were satisfied with the service

Children & families (Fit Families) Service

≥35% service users achieving reduction in BMI centile at 3 months

≥50% service users achieving BMI centile reduction at 3 months who have maintained this BMI centile reduction at 6 months

at least 90% of service users responding to the satisfaction survey must report that they were satisfied with the service

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Appendix 1 Weight Management Service Delivery Options

Behavioural support

Pharmacotherapy

Establishing

weight

status

Other

service

components

Must offer

one-to-one support; and/or

closed group support; and/or

proactive telephone outreach

Face to face

appointment to

ascertain BMI/

BMI centile

measurement

May offer

in

agreement

with H2C

reactive telephone support

text (SMS) support

relapse

prevention

physical

activity

intervention

Must

not

offer

weight management support

not in line with current NICE

guidance

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APPENDIX 2 Behaviour change support in weight management

The purpose of behaviour change support in weight management is to increase a service user’s ability to successfully change an unhealthy behaviour. This occurs when a service user talks positively about change and the role of the Weight Management Advisor is to facilitate and support this. Help2Change training includes motivational interviewing techniques to support weight management advisors in using a collaborative, person-centred guiding approach to elicit and strengthen a service user’s motivation for change.

Behaviour change support may be delivered face-to-face (individually or in groups) and via other means including telephone or motivational text messaging. It aims to support service users to achieve and maintain a healthy weight by:

establishing a rapport

exploring importance, building confidence and negotiating change

providing structure, direction and support

agreeing target weight change and finding individual solutions to change

helping service users to increase and maintain their motivation to change

boosting self-confidence and maximising self-control

Definitions

One-to-One Support: Refers to an intervention between a weight management adviser and a service user, at a specified time and place. It is usually delivered face-to-face.

Closed group Support: Refers to a face-to-face intervention facilitated by weight management adviser/s, with a number of service users at a specified time and place. A minimum of eight group members is recommended.

Proactive telephone support: Should be delivered by weight management advisers and follow the same specification as one-to-one support. It should begin and end with a face-to-face session for assessment of weight status. All proactive telephone interventions should have a total potential contact time with the service user as detailed in Appendix 4-5 for the purpose of regular monitoring and service compliance.

Reactive telephone support: Should be delivered by weight management advisers as part of routine support including relapse prevention.

Drop-in Support: A face-to-face intervention provided at a specified venue/venues at an unallocated time (although may be a specified time slot, e.g. between 10.00-12.00 noon). The service is provided by an individual weight management adviser with an individual service user within the wider confines of an open access service. While venues and appointment times can be flexible, the service user must be advised to attend regularly to get the maximum benefit.

Text (SMS) support: There is currently insufficient evidence to demonstrate the efficacy of text support as the main intervention type. However, text may prove useful as part of a wider support programme or as a way of recruiting service users, reminding them of appointment times or providing ongoing reactive support.

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Appendix 3 Prescribing Protocol for anti-obesity Medication within

Help2Slim Adult Weight Management Service

This protocol covers anti-obesity drugs included in section 4.5 of the BNF, currently the only available product is orlistat (Xenical®). In line with current NICE guidelines, the effect of drug treatment should be monitored and lifestyle advice and adherence should be reinforced through regular review.

The prescribing of orlistat (Xenical®) is at the discretion of an appropriate clinician and should only

occur when diet and exercise have been tried, after discussion of risks and benefits and with

continued support for lifestyle change.

For prescribing orlistat (Xenical®) as part of the Help2Slim adult weight management service:

o Orlistat (Xenical®) is indicated in conjunction with a mildly hypocaloric diet for the treatment of

obese patients with a body mass index (BMI) greater or equal to 30 kg/m², or overweight patients

(BMI > 28 kg/m²) with associated risk factors

o Treatment with orlistat (Xenical®) should be discontinued after 12 weeks if patients have been

unable to lose at least 5% of the body weight as measured at the start of therapy

o The recommended dose of orlistat is one 120 mg capsule taken with water immediately before,

during or up to one hour after each main meal. If a meal is missed or contains no fat, the dose of

orlistat should be omitted

o The patient should be on a nutritionally balanced, mildly hypocaloric diet that contains

approximately 30% of calories from fat. It is recommended that the diet should be rich in fruit and

vegetables. The daily intake of fat, carbohydrate and protein should be distributed over three main

meals

o Doses of orlistat above 120 mg three times daily have not been shown to provide additional benefit

Weight Management Advisors are fully aware of these requirements

Reference: NICE clinical guideline 43; Summary of Product Characteristics - Orlistat (Xenical®)

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Appendix 4 Outline Children & Families (Fit Families) Weight Management Service

90 mins 60 mins 60 mins

Baseline 1 Month 3 Months 6 Months 12 Months

8 Hours 6 Hours Follow up

appointment at

12 months

Key:

Flexible appointments (e.g. face to face, telephone contact, text, other etc.) Number, duration, style and spacing of

appointments flexible according to individual service user needs/preferences

Must be face to face appointments, duration fixed, may include home visits

90 mins 15 mins

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Appendix 5 Outline Adult (Help2Slim) Service

30 mins 30 mins

Baseline 1 Month 3 Months 6 Months 12 Months

1½ Hours 1½ Hours 1½ Hours Follow up

appointment at

12 months

Key:

Flexible appointments (e.g. face to face, telephone contact, text, other etc.) Number, duration, style and spacing of appointments

flexible according to individual service user needs/preferences

Must be face to face appointments, duration fixed

30 mins 15 mins

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Appendix 6: Service user

satisfaction questionnaire