Senior Management Team 24 November 2011 Item 3(v) NHS HIGHLAND HEALTHY WEIGHT STRATEGY HEALTHY WEIGHT CARE PATHWAY PILOT OF TIER 3 SERVICE Report by Roseanne Urquhart, Head of Healthcare Strategy (Chair, NHSH Weight Management Group) and Fiona Clarke, Senior Health Promotion Specialist The Senior Management Team is asked to: Approve a 12 month Pilot of specialist Dietetic-led weight management service for a cohort of patients with severe and complex obesity; Agree that monitoring of the Pilot is undertaken by the NHSH Weight Management Group, with update/outcome reports to the Senior Management Team by the Chair of that group, Roseanne Urquhart, Head of Healthcare Strategy. Note that funding would need to be identified to provide sustainable Tier 3 services for the long term. The outcomes of the pilot will inform the development of these services. 1. INTRODUCTION 1.1 Purpose of Paper On 29 September 2011 the Senior Management Team (SMT) supported in principle the recommendation from the Clinical Advisory Group (CAG) to Pilot a Tier 3 Dietetic-led specialist service for patients with severe and complex obesity. This Project Plan specifies the project in terms of scope, evaluation framework and resources needed for delivery. 1.2 The Pilot New national criteria for bariatric surgery are expected to be adopted in April 2012 and it is anticipated that this change of criteria will have a significant impact on Highland patients who are currently on the NHS Grampian (NHSG) waiting list for bariatric surgery. It is unlikely that any of those patients will meet the new criteria and they will therefore be discharged back to their GPs. This Pilot is part of a tiered approach to obesity management which also involves community and primary care interventions. The aims of the Pilot are two-fold: a) To test what is seen as best practice for Dietetic-led Tier 3 services and assess that practice within the Highland context. b) Offer an evidence-based service to the above Highland patients on NHSG waiting list to ensure they are not left with the view that they are being abandoned by NHSH. The objectives are to: Provide a Dietetic-led weight management intervention to 90 patients throughout NHS Highland (NHSH) (60 in north Highland and 30 in Argyll and Bute) with severe and complex obesity over 12 months Mentor Primary Care practitioners to support ongoing self management for these patients Develop competencies for the health weight workforce Evaluate the delivery of this model of care within the Highland context which includes rurality challenges perhaps not experienced elsewhere Provide reassurance to the NHSH Board that the current cohort of patients on the NHSG waiting list are offered an appropriate service.
3 THE PROPOSAL 3.1 Tier 3 Dietetic-Led Service The proposed pilot represents a pragmatic approach to address an imminent issue in respect of those patients about to be discharged from the weight management services (WMS) in Grampian, taking cognisance of the available resource and expertise in Highland to ensure that services are developed and delivered in a timely and effective manner. It is recognised that this cohort of patients may not represent the ideal population for a Tier 3 trial of this nature as many of these patients will have been accepted onto the Grampian waiting list without first undertaking any form of structured weight management intervention. Many would have been referred directly by their GP and the majority will have a very real expectation that they will undergo bariatric surgery at some point in the future. The criteria for admission to the Pilot are where patients were referred to the WMS in Grampian but have only made limited progress through the WMS (either because of capacity issues in NHSG or the need for continued WMS support). There are currently 60 patients in north Highland who meet this criteria and 30 patients from Argyll and Bute. Appendix 1 details the assumptions and criteria used to determine how patients have been selected for admission to the Pilot and what other actions will be followed for those patients not in the Pilot. A local Tier 3 Service would use the evidence from service models in other parts of the country which are based on high intensity input which produces better outcomes, with regular professional support as a central feature. Patients will be offered ten structured individual interventions over six months in the form of a detailed assessment; six appointments over 13 weeks and three over the following 13 weeks, with the option of additional support from psychological therapies and/or physiotherapy where indicated. A key feature of the Pilot is the mentoring of practitioners offering Tier 2 service to ensure an efficient handover of care. This will support enhancement of skills and knowledge in weight management and behaviour change, for Primary Care practitioners. Patient outcomes Improvements to diet (fruit and vegetable intake, fibre, Omega 3 fatty acids) Improvements to physical activity/sedentary behaviours Improvements to co-morbidities and weight Improved mental health and wellbeing Self efficacy Reduced eating disorder symptomology Reduction in medication useage (both prescribed and over the counter) Reduction in frequency of other health appointments Participation in community activities Patient satisfaction with service Service outcomes Evidence and practice-based recommendations for the development of sustainable Tier 3 Services Defined practitioner competencies to deliver healthy weight interventions at Tier 2 and Tier 3 Appropriate utilisation of resources Reduced impact on other services Reduction in the number of complaints received 2
Staffing and Timeline If approved, it is proposed to commence preparatory work on the Pilot as soon as possible and by January 2012 at the latest. In north Highland the Pilot will be led by a part time Dietitian working 3 days per week (22.5 hours), supported by an administrative assistant working a total of 150 hours over the duration of the project. Argyll and Bute are currently considering their staffing requirements and a similar proposal reflecting the north Highland staffing structure will me made to the Argyll and Bute CHP Planning Group in due course. The Pilot is anticipated to last 12 months, which takes account of annual leave entitlements etc. The planned timeline and project structure is given at Appendix 2. It is planned to start face-toface contacts with patients from mid-february 2012 and the patients will be seen in two cohorts. The first cohort of patients will be from Inverness and environs; the second cohort will be from further afield e.g. Thurso, Skye, Wester Ross, etc. This second cohort will be seen from early June 2012. Patients will have an assessment plus up to ten contacts with the Specialist Dietitian. Each contact would take the form of a 1:1 consultation, the initial contact being within a clinic setting at a central location, with subsequent consultations being delivered via V/C if appropriate/available at structured intervals. 3.2 Resources / Costs North Highland The costs for the Pilot in north NHSH are estimated at 45,621; these are detailed in Table 1 at Appendix 3. It is proposed to fund the Pilot from a provision within the tertiary budget that was originally earmarked for bariatric surgery. Argyll and Bute Argyll and Bute have identified resource within their current bariatric allocation and endorsement of this spend will be subject to a paper being submitted to the Argyll and Bute CHP Planning Group in due course. In the event that the Pilot proves successful, funding would need to be identified to provide sustainable Tier 3 services across NHSH for the long term further details on the indicative costs of a sustainable Tier 3 service will be discussed within the interim report to SMT in Month 9 of the Pilot. 3.4 Monitoring of Pilot The NHSH Weight Management Group includes representation from Planning, Dietetics and Psychology. The full membership is given at Appendix 4. It is proposed that this Group monitors the delivery, evaluation and outcomes of the Pilot and reports to the SMT as appropriate. Monitoring will be based on patient and service outcomes and developed during the Project Initiation phase of the Pilot. An initial evaluation report will be submitted to SMT by month 9 of the Pilot to allow timely consideration of whether or not to establish a sustainable Tier 3 service and will include interim findings for 2 to 30 patients. The final report will be submitted in early 2013. Should a decision be taken to develop sustainable Tier 3 services in Highland, it is proposed that the evaluation framework should remain in place for five years. During this period, regular monitoring reports would be submitted to SMT, with a final report outlining the key outcomes of the service at the end of year five. This will ensure that there is sufficient data available to inform the debate around the effectiveness of a dietetic-led approach. 3
4. COMMUNICATIONS Should permission to proceed with the Pilot be given, the NHSH Weight Management Group will communicate with GPs and invite eligible patients to participate in the Pilot. Other patients will be asked to wait until the Pilot is completed, in anticipation of the rollout of a sustainable NHSH Tier 3 service. Communication with patients will be informed by the NHSH Head of PR and Engagement. Should a decision be taken not to invest in Tier 3 services, these patients will remain under the care of Primary Care. The NHSH communications strategy in respect of any change to the criteria for surgery will be informed by the national communications strategy for the National Planning Forum and will be led by the SGHD Communications Team. 5. SUMMARY The Tier 3 Pilot will be undertaken over a period of 12 months and will provide a service and evidenced based interventions for a cohort of up to 90 Highland-wide patients with severe and complex obesity. The findings of the Pilot will inform the development of a sustainable Tier 3 service, and enhancement of Tier 2 services. Once a sustainable Tier 3 weight management service is in place, NHSH might then consider whether it is appropriate to invest in the development of structured access to Tier 4 services (bariatric surgery). Roseanne Urquhart Head of Healthcare Strategy (Chair, NHSH Weight Management Group ) Fiona Clarke Senior Health Promotion Specialist 16 November 2011 4
Appendix 1 NHSH WEIGHT MANAGEMENT GROUP ASSUMPTIONS AROUND ACCESS TO WEIGHT MANAGEMENT PATHWAY 1. Where patients were referred for the WMS in Grampian and have successfully completed all assessments and treatment requirements and considered suitable for Bariatric Surgery (or were about to go through final assessment with a strong likelihood of success), these will be offered surgical assessment at GJNH. 2. Where patients were referred to the WMS in Grampian but have only made limited progress through the WMS (either because of capacity issues in NHSG or the need for continued WMS support), these patients will be offered a place on the Pilot. 3. Where patients have already received surgery (private or NHS funded), no further surgery will be funded. 4. Where patients are requesting surgical revision, these will not be generally funded, unless through exceptional circumstances. 5. Where patients have not been referred to NHS Grampian WMS then they will be put on the list for the post-pilot service, on the expectation that a sustainable WMS will be introduced to NHSH. 6. Should there be free capacity within the Pilot, patients from the existing NHSH waiting list will be invited to join the Pilot, based on their referral date. 7. Where patients have elected to discharge themselves or where they have DNAd or CNAd for clinical appointments, they will be managed according to the NHSH Department of Nutrition and Dietetics Policy and Procedures for Managing Access for Patients (November 2009) see summary, below. 8. Patients from A&B CHP have been noted but will continue to follow the WMS currently under development. 9. There will be No Further Action for NHSH patients who were directly referred to NHSG and for whom we have no information. SUMMARY OF NHSH DEPARTMENT OF NUTRITION AND DIETETICS POLICY AND PROCEDURES FOR MANAGING ACCESS FOR PATIENTS 1 x DNA: Discharge from dietetic care unless clinical judgement determines a further appointment or alternative consultation is required. Inform referring agent. 3 x CNA: Discharge from dietetic care unless clinical judgement determines a further appointment or alternative consultation is required. Inform referring agent. 5
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Appendix 3 RESOURCES / COSTS The costs for the Pilot in north NHSH are estimated at 42,621; these are detailed in Table 1 below. Table 1 Costs for Tier 3 Weight Management Services for 60 Patients (north NHSH) TIER 3 PILOT COSTS Staffing Requirements Hours Cost ( ) Dietitian (Band 6) 953 25,263 Psychologist (Band 8c) 135 5,950 Administrator (Band 4) 150 2,508 Equipment Supplies and Services Scales and bariatric chairs 4,800 Travel and subsistence 2,500 Training 700 HAD Licence 3,000 Postage and stationery 150 Miscellaneous 750 Grand Total 45,621 Costs provided by Joe Devlin 16 November 2011 7
Appendix 4 NHS HIGHLAND WEIGHT MANAGEMENT GROUP Membership Roseanne Urquhart, Head of Healthcare Strategy (Chair of WMG and Project Lead) Fiona Clarke, Senior Health Promotion Specialist Judith Catherwood, AHP Associate Director Deborah Kirby, Lead for Dietetics, A&B Margaret Moss, Professional Head of Service, Dietetics Paul Nairn, Service Planning Manager Sheelagh Rodgers, Consultant Psychologist Mairi Wotherspoon, Specialist Dietician 8