Background to the Service

Background to the service

Obesity is one of the most significant health challenges facing the UK. It is responsible for a negative impact on the health and well-being of individuals. The financial impact on the NHS and the wider economy are also high in terms of treatment, loss of earnings and reduced productivity.

The previous government had set itself a new ambitionof “being the first major country to reverse the rising tide of obesity and overweight in the population by ensuring that all individuals are able to maintain a healthy weight” and set out an expectation that PCTs will increase commissioning of these services

NHS Central Lancashire’s pilot pharmacy weight management service

The pharmacy weight management service involved 12 structured one to one sessions with the pharmacist delivered over a period of 12 months. Patients could self-refer or be referred into the service by any health professional working in the PCT’s Weight Management Care Pathway. The client is assessed for suitability for inclusion, their consent obtained and their GP notified. Various parameters such as weight, waist circumference, blood pressure and BMI are taken from clients during the sessions. The pharmacist uses motivational interviewing techniques to engage the client into adopting a healthy lifestyle involving a change in their diet and nutrition and increasing levels of physical activity.

Evaluation methods

The primary evaluation was a questionnaire survey devised to obtain feedback from primary stakeholders: clients, pharmacists and GPs. The secondary strand of evaluation was the analysis of the operational data regarding the key performance criteria which were: weight, waist circumference, BMI and blood pressure.

Results – operational data

Operational data was collected over the period from December 2008 till end March 2010. In this period 100 patients were assessed for suitability for inclusion; of these 87 were suitable, 5 were referred to other services such as to their GP and 8 were unaccounted for. Out of the 87 deemed suitable 58 proceeded to attend their first session.

Fig 1 below shows clearly the reduction in weight loss over the course of the service.

A similar trend may be observed in all the other key performance criteria, Table 1.

Table 1: Key service performance data

SESSION
Initial Assessment / S1
Wk 1 / S2
Wk 2 / S3
Wk 4 / S4
Wk 6 / S5
Wk 8 / S6
Wk 10 / S7
Wk 12 / S8
Wk 16 / S9
Wk 20 / S10
Wk 24 / S11
Wk 36 / S12
Wk 52
Number of Patients attended / 100 / 58 / 55 / 48 / 45 / 44 / 42 / 40 / 11 / 8 / 5 / 5 / 5
Average weight loss since assessment (Kg) / 0 / 0.02 / -0.47 / -1.00 / -1.35 / -1.52 / -1.63 / -2.06 / -1.70 / -2.23 / -2.44 / -2.26 / -2.88
Average BMI reduction since assessment / 0 / -0.55 / -3.60 / -2.12 / -2.14 / -2.37
Average BP reduction since session 1 / 0 / 0 / -5/2 / -4/2 / -2/4 / -9/6
Average waist circumference loss since initial assessment / 0 / -0.02 / -1.72 / -2.63 / -2.97 / -3.44 / -3.49 / -3.82 / -4.25 / -6.50 / -6.80 / -6.80
Number of patients with weight loss per session from baseline / 37
67% / 39
81% / 40
89% / 40
91% / 37
88% / 33
83% / 10
91% / 7
88% / 4
80% / 4
80% / 4
80% / 37
67%

There were five clients who had reached the last session of the programme at the time of the evaluation - session 12, week 52. Four of these had achieved weight loss, the average loss being 4.13 kg with a range of weight loss from 0.6 kg to 7 kg. Two out of these clients achieved a weight loss of more than 5%.

In order to test whether a significant change had occurred for clients the weight and waist circumference measurements for each client were comparedbetween their initial assessment and Session 7 (the stage which most clients had reached). There were 40 pairs of weight measurementscompleted forthis period, and 39 pairs of waist measurements. Each set of paireddata was interrogated using arelated samples Wilcoxon Signed-Ranks Test (conducted using the statistical software PASW Statistics 18 - formerly SPSS). For both weight and waist measurements, a significant change was confirmed at the level p<0.05. Only seven of the clients had increased their weight over this period, and only 4 had increased their waist circumference.

Results – client experience

The most successful method of client recruitment proved to be self-promotion in the pharmacy
Almost all clients reported that they had increased their physical activity
Almost all clients reported that they had changed their diet to include more healthy options
Of the three clients who had completed the full programme at the time of the evaluation, one had achieved the goals set and a second one had almost done so
The clients were overwhelmingly positive about the service being delivered from pharmacies for a range of key indicators such as pharmacists’ input, the consultation sessions (including the materials provided, privacy and confidentiality), being motivated to succeed and having their body measurements taken.
The clients stated they liked the informal and friendly environment of pharmacies, easy access to the service, and the one-to-one sessions with the pharmacists and the fact that the service was free.
Reasons for clients leaving the service or not wanting to access it in the first place needs further exploration.

Results – service provider (pharmacist) experience

Positive aspects of the service were found to be: increased interaction with customers through the consultation sessions; taking client measurements; promotional literature supplied e.g. leaflets
The principal challenge experienced was in the recruitment and retention of clients which was attributed to the lack of any widespread promotional activity
Some clients had expectations of being given weight-loss medication
No issues of privacy was encountered
Training provided by the PCT was satisfactory with information regarding motivational interviewing techniques and measurement taking being most useful
There was uncertainty regarding whether more use should be made of other pharmacy staff such as technicians
There was a lack of referrals from GPs and other HCPs
Equipment provided was easy to use and fit for purpose. A third of pharmacists used the equipment for providing services other than the pharmacy weight management service
Involvement in providing this service resulted in pharmacists acquiring greater knowledge of weight management as a public health issue and greater pharmacist-customer interaction leading to an improved public image
Barriers encountered in the provision of the service were: size of consultation rooms; client expectations; insufficient publicity/promotion, and; lack of GP engagement

Results – GP experience

Only one completed GP questionnaire was returned out of a total of 89 surgeriesthey were sent to. This response rate is insufficient to get a true opinion of GP involvement and therefore this part of the evaluation was not completed.

Discussion

Clinical and cost effectiveness

This evaluation shows that the pharmacy weight management service is clinically effective because it has produced positive outcomes in terms of reductions in weight, waist circumference, BP and BMI in clients that accessed the service. They were able to achieve this by increasing their physical activity in numerous ways and by adopting healthy eating habits. One to one advice and counselling with the pharmacist proved a principal motivating factor in this. This is in line with previous research examining the impact of pharmacists’ advice on subsequent health behaviour which found that the majority of clients (at four weeks follow up) had followed the advice they had received as part of a local health promotion scheme (Ghalamkari et al, 1997).

Direct comparisons with other similar pharmacy weight management services is difficult due to the variations in service provision such as provision of exercise passes (Medway), client group meetings (Medway) and the Coventry scheme in particular was supported by one of the leading national pharmaceutical wholesalers and also had the backing of the Department of Health. Similarly it would be difficult to compare this service with weight management services provided from other settings and with pharmacological interventions. Only a correctly designed randomised controlled trial would facilitate this.

An in-depth cost analysis is outside the scope of this evaluation. However a simple comparison focusing on direct costs may be made with the most commonly prescribed pharmacological intervention – orlistat (Xenical). Since orlistat should not be prescribed to clients beyond week 12 of treatment unless they have achieved a weight loss of more than or equal to 5% of their initial body weight, Table 2 shows the cost of the two interventions at week 12 and week 52 and omits indirect costs such as set up fees, cost of equipment, GP consultations and reviews.

Table 2: Directs costs of orlistat and the pharmacy weight management service

Week 12 / Week 52
Pharmacy weight management service / £110 / £160
Orlistat (Xenical) 120mg tds / £96.81 / £419.51

Although the pharmacy service is more expensive than Orlistat up to week 12, it is significantly cheaper over a full year’s treatment.

Client and Provider experience

Almost all clients stated they had a positive experience of accessing the weight management service through the pharmacy setting with favourable aspects being: convenience and accessibility, the pharmacy environment itself (friendly, comfortable), having a structured one-to-one consultation and the professionalism of the pharmacist. This mirrors some of the key factors important in commissioning pharmacy based services outlined in World Class Commissioning (2009) which are: ease of accessibility and a convenient and less formal environment. Furthermore, most clients indicated that they preferred this service over the commercially available ones they had tried. This outcome adds more valuable evidence to previous research in this field which has shown time and again the positive experience of clients in accessing novel health services through pharmacies, examples include minor ailment schemes (Gray, 2009; Pumtong, 2007; Vohra, 2006), cardiovascular risk assessment (Blenkinsopp, 2009), dermatology (Carr et al, 2007), EHC via PGD (Lambeth, Lewisham and Southward health Action Zone, 2002) and improving public health (Anderson et al, 2004).

A further positive finding was that no issues of privacy or confidentiality surfaced. This is an improvement from previous research (Anderson et al, 2004) which found clients were concerned about these issues when accessing services at the pharmacy. However, since then, the advent of the new community pharmacy contractual framework has made providing private consultation rooms vital especially for the provision of advanced services (i.e. MURs) and this was one of the key criteria of inclusion for pharmacies to participate in this pilot service. However, many pharmacists found it difficult to take client measurements due to the inadequate size of their pharmacy’s consultation room. In the future the PCT should ensure that the consultation room in pharmacies wanting to provide the service is adequate from the point of view of a weight management service not MURs.

The biggest challenge by far faced by pharmacists was the recruitment and retention of clients. Examination of the reasons for leaving the service before its completion did not reveal much since the comments recorded were not specific. It is interesting to note here that some patients expected a ‘quick fix’ or some form of weight loss medication and were put off when these were not forthcoming. There are PCO commissioned weight management services which involve weight loss medication and the document Choosing Health through Pharmacies advises PCOs to use this route where appropriate (via PGDs or the non-medical prescribing route) in addition to the provision of healthy lifestyle advice and weight checks. Future evaluations should ensure that the issues (client expectation and retention) is explored in more depth as this may provide valuable feedback to inform future planning and commissioning of the service. Problems with recruitment and retention are consistent with previous research findings in other enhanced services such as smoking cessation (Agomo, 2006; Maguire et al, 2001) and the Coventry weight management service also experienced problems with this. Pharmacists felt that there was little promotion of the service but this is to be expected considering that the service was a pilot, being offered from about a fifth of pharmacies in various geographic areas and, therefore, widespread promotional activity may not have been appropriate or cost-effective. Recruitment could have been aided by greater GP engagement. GP engagement with the pharmacy service and this evaluation was poor. There appears evidence of engagement by the pharmacist with GPs but not vice versa. Two pharmacists did indicate that there was a clash between the pharmacy service and surgery based weight management services. However this does not explain the poor response in all the pharmacy sites. GPs are required to produce a register of patients aged 16 and over with a BMI greater than or equal to 30 as part of their Quality and Outcomes Framework (2009-10); this should have provided a ready list of patients that could have been referred onto the pharmacy weight management service. The PCO needs to explore this issue further since GP engagement and involvement is important not just in terms of collaborative working but also to ensure that all patients who would benefit are identified and given the opportunity to take advantage of a free NHS service.

The use of the equipment provided for non-pharmacy weight management services and the lack of enthusiasm for more pharmacy technician involvement in the service merits some attention. Pharmacists found multiple uses for the equipment, the most notable being their use during MURs and OTC purchases of Alli to check patients’ BMI. Community pharmacists may like to consider investing in such equipment to enhance their practice. Nine technicians were accredited to provide the initial component of the service yet the majority of pharmacists indicated that their technicians were not involved and less than half wanted their technicians to become more involved. This issue needs further exploration to ascertain why the accredited technicians were not used and why pharmacists do not want greater involvement of technicians in the service. It may simply be that the ‘wrong’ pharmacy staff was involved and the PCT should consider the use of pharmacy dispensers and OTC assistants to deliver some parts of the service.

Have the aims of the service been achieved?

The pilot pharmacy weight management service has provided evidence of its success by fulfilling the aims of the service (Table 3). Most clients found the service to be accessible and convenient and all were positive of pharmacists’ input to the extent that the majority of clients indicated they preferred the pharmacist to provide the service rather than another HCP. People at risks of obesity related illnesses were identified and encouraged to participate in the pharmacy weight management service. Although not all clients judged at risk commenced onto the service, two thirds did do so and their GPs notified of this. Most clients lost weight over the course of the service and almost all began to increase their levels of physical activity and eat healthier through being given targeted advice and motivational support. These changes to lifestyle should lead to an improvement in the quality of life experienced by clients; however this issue was not determined via the client questionnaire and ascertaining it objectively was outside the scope of this evaluation. Although referral of at-risk clients was low from GPs and other HCPs the pilot pharmacy weight management service did increase partnership working as most participating pharmacists visited their nearest surgery to raise awareness of the service and three pharmacies did have clients referred to them from GPs.

Table 3: Service aims and evidence of their being met.

Aim / Evidence / Outcome

To increase access to weight management services in terms of location, available times to be seen and type of professional consulting.

/ Clients found the PMWS convenient and accessible
All clients were positive about pharmacists’ input / Achieved

To identify those at risk and to help to populate GP risk registers. To identify those who are “ready to change” and who can therefore be directed to a suitable service or programme.

/ From the operational data 100 customers were assessed, 87 were indicated for the pharmacy weight management service, 5 were referred to other HCPs and 58 commenced onto the pharmacy weight management service. A GP notification form was completed for the 58 who commenced the service. / Achieved

To reduce obesity levels in patients over the age of 18 years and that have a BMI greater than 25 but less than 39.9 or whose circumference puts them at risk of developing a long term condition.

/ Over the course of the service most clients experienced a reduction in weight, BMI, waist circumference and BP (Fig 1; Table 1) / Achieved

To improve the quality of life and longevity of patients identified in Aim 3 as the result of developing preventative services.

/ It is assumed that by taking up a healthier lifestyle e.g. by increasing their levels of physical activity and changing to a more healthy diet, clients will have improved their quality of life. However, whether the pharmacy weight management service improved longevity is beyond the scope of this evaluation. / Partially achieved

To provide targeted advice and motivational support to overweight and obese patients on improved diet and nutrition, increase levels of physical activity and promotion of healthy weight by setting achievable goals on a regular basis.

/ Almost clients had increased their level of physical activity and healthy eating.
One-to-one consultations with the pharmacist increased clients motivation and confidence. / Achieved

To increase partnership working and improve communication between pharmacists, GP practices and other healthcare professionals to develop integrated and high quality services for patients.

/ Low rates of GP referrals and none from other HCPs despite the fact that most pharmacists had talked to their GPs before the service launch.
A GP PEC member had been instrumental in designing the service. The service was presented to GPs for their comment and input at a PETS (protected education training session) and there were favourable responses. / Partially achieved

To enhance pharmacists’ professional practice in alignment with the “Darzi vision” and the Pharmacy in England vision.

/ Clients were positive about pharmacists’ input and their experience of the pharmacy weight management service.
Pharmacists gained increased knowledge, confidence and job satisfaction as well as increased client-pharmacist relationship and improved professional image. / Achieved

Conclusion