Weight Management Service
June 2008
Protocol Notes
PREPARED BY:
UNICHEM LTD PROFESSIONAL SERVICES DIVISION
Acknowledgementsv Acknowledgment is given to all participating and supporting organisations, including Plymouth Teaching PCT and its participating pharmacies:
v Special acknowledgment is also given to the following individuals who contributed towards the development of this programme:
§ Dr Gill Lewendon, Consultant in public health
§ James Glanville, Primary Care Manager
§ Oksana Riley,Prescribing Advisor
§ Sue Taylor Chief Officer, Devon Local Pharmaceutical Committee
ContentsPage
Introduction 4
Obesity and Plymouth Teaching PCT 4
The Role of Community Pharmacists 5
Weight Management Service:
o Aim 6
o Objectives 6
o Outcome Measures 6
o Pharmacy & Pharmacist Selection 6
o Patient Inclusion Criteria 7
o Patient Exclusion Criteria 7
o Patient Recruitment Numbers 7
o Confidentiality & Data Protection 7
Methodology
o GP Briefing 8
o Service Process 8
o Role of Pharmacy Support Staff 9
o Pharmacist Intervention & Referral Criteria 9
o Data Flow 9
o Diagnostic Equipment 10
o Clinical Governance 10
Service Flowchart 11
Management of documentation 12
Patients Booklets 13
Remuneration 13
Contact Details 13
References 13
Appendix 14
o Participating Pharmacies 15
o Advice & Recommendations Section 16
o Supplier Details 25
o Sample Documentation 26
IntroductionImpact of Obesity
Over half the UK population are now either overweight or clinically obese, and according to latest reports, if current trends continue at least one-third of adults, one-third of girls and one-fifth of boys could be clinically obese by 20201.
Obesity is now well recognized as a disease in its own right, and is largely preventable through changes in diet and lifestyle. However, it is clearly established that being overweight or obese increases the risk of coronary heart disease (CHD), cancers, diabetes, hypertension, stroke, respiratory problems and osteoarthritis, and is associated with a reduced life expectancy. As well as these debilitating conditions, being overweight or obese can have detrimental effects on self-esteem and social life. Worldwide, around 58% of Type-2 diabetes, 21% of CHD and between 8% and 42% of certain cancers are attributable to excess body fat. In England alone, obesity is responsible for more than 9000 premature deaths each year, reducing life expectancy on average by nine years2.
The financial cost to the NHS is estimated to be around £500m a year in treatment costs3. The use of anti-obesity drugs, under NICE guidelines4, has trebled since 2001 putting increased pressure on drug budgets.
The NHS Plan5 makes a commitment to improve the overall balance of the diet and increase the activity of the population. The benefits of weight loss are well documented6 and setting realistically achievable targets is important. Just a 10% weight loss can reduce:
· Mortality by up to 25%
· Blood pressure (systolic and diastolic) by 10mmHg
· Diabetes risk by over 50%
· Fasting blood glucose by up to 50%
· HbA1c by 15%
· Total cholesterol by 10%
Obesity and Plymouth tPCT
Much in the prevention of overweight and obesity and in the promotion of healthy choices is related to access to healthy diet and increased activity levels of the whole population. Many agencies, including community pharmacists, can impact directly on this and have the potential to effect a positive change in health - thereby reducing the impact of obesity on the health services. The PCT is committed to providing advice and support for people wanting to lose weight through a wide range of services including specialist adult and children’s obesity clinics, a family orientated community weight management programme - ‘Active for Life’, motivational courses and cooking skills in the community. The Community Pharmacy weight management service will provide an important component of our community based approach to tackling obesity in the City.
The Role of Community PharmacistsA well-informed, motivated community pharmacy team are appropriately placed to play a central role in providing advice and ongoing support for overweight and obese people. The strategy for tackling overweight and obesity needs to incorporate a number of factors:
· Ready access to advice and support
· Publicising the benefits of weight management
· Inter-professional collaboration
· Ongoing support and monitoring
Causes of Overweight and Obesity:
· Underlying cause of overweight and obesity is where an individual has an excess of energy intake over energy expenditure
§ Calorie intake greater than calorie burn-up
· Other associated factors include:
§ Behavioural
§ Environmental
§ Social
§ Genetic
Community pharmacists are an integral part of the primary healthcare team. It has been widely recognised that better use can be made of their skills and knowledge for the successful provision of high quality, patient-centred services and the rational, cost-effective use of medicines.
Under both the new General Medical Services (nGMS) Contract and Community Pharmacy Contract, healthcare professionals will need to work together more closely to demonstrate seamless patient care through the development and implementation of Enhanced Services at a local level.
Weight Management ServiceAim
To provide a weight management service for people with a Body Mass Index (BMI) 30 -38 kgs/m2 and at least ONE established risk factor.
Established Risk factors are:
§ Increased Waist Circumference – Male 102cm (40ins) & Female 88cm (35ins)
NB: Asian men should be below 90cm (36 inches) & Asian women should be below 80cm (32 inches)
§ Hypertension
§ Type-II Diabetes
§ Hyperlipidaemia
Objectives§ To facilitate a weight loss of at least 5%
§ To identify obese patients “at-risk” of developing long-term conditions
§ To educate the patients in healthy living
§ To explore the role of community pharmacists in the primary health care team and the extension of that role into the provision of clinical pharmacy services
§ To explore the potential to extend the role of community pharmacists in weight management
Outcome Measures§ Number of recruited patients achieving a weight loss of ≥5% of recruitment weight
§ Nature and number of pharmacist interventions
§ Number of people identified “at-risk” of developing a long-term condition
§ Number and nature of referrals to GPs
§ Number of people with poorly controlled Type-II diabetes
§ Nature and number of patients referred to community pharmacies by GP practices
§ Assess and evaluate patient and pharmacist satisfaction with the service
Pharmacy & Pharmacist SelectionThe service will involve six community pharmacists selected by Plymouth Teaching PCT, one from each of the six localities using the following criteria to ensure optimal service delivery and output:
§ Pro-active pharmacist enthusiastic about opportunity presented by programme
§ Pharmacy has consultation area that has been verified during monitoring visits to meet contract specification
§ A sink is available for use
§ Pharmacy has achieved a satisfactory contract monitoring report 2007-8
§ Pharmacist is HEI accredited for providing MUR service
§ Pharmacy has demonstrated through past performance that it will actively engage and support local initiatives and services
§ Commitment to time by pharmacy staff for service implementation and delivery including involvement from at least one named member of pharmacy staff to attend the training event(s) and facilitate service delivery
Patient Selection CriteriaPatient Inclusion Criteria
The service will be offered on an opportunistic basis to patients meeting the following criteria:
§ Adults over 18 years age
§ Adults with a BMI 30kg/m2 and ≤ 38kg/m2, plus ONE established risk factor (Increased Waist Circumference, Hypertension, Hyperlipidaemia or Type-II Diabetes)
Patient Exclusion Criteria
Patient with the following criteria will be excluded from the programme:
§ Adults under the age of 18 years
§ Adults with a BMI <30kg/m2 and >38kg/m2
§ Pregnant or breastfeeding women
§ Where in the pharmacist’s professional opinion, the poor state of health of the person should preclude their participation as it would not be in the person’s best interest to take part
People who are not suitable for inclusion onto the programme can be signposted to alternative local services Information on what is available can be obtained from Sarah Hind, Weight Management Service, Cumberland Centre, Dameral Close, Devonport PL1 4JZ tel 01752 434623/314661
Patient Recruitment Numbers
Each pharmacy to recruit 10 patients onto the programme for a 12-month duration. The initial intervention is anticipated to involve the pharmacist for approximately 30 minutes. Pharmacy support staff may assist patients to complete questionnaires, and, after appropriate training, assist in the measurement of monitoring parameters under the supervision of a trained pharmacist
Patients may be recruited onto the programme by:
§ Self – referral where the above inclusion criteria have been met
§ By information flyers from Plymouth Teaching PCT and the Active Plymouth websitep
§ By referral from Specialist services
§ Referral through GP surgeries for people who have volunteered/expressed an interest in the programme
§ Pharmacists/Pharmacy Staff to refer suitable people onto the programme through prescription interventions and medicines-use-reviews
Confidentiality & Data ProtectionThe pharmacy is registered under the Data Protection Act 1998, its predecessor Act and the RPSGB Code of Ethics (see Medicines, Ethics and Practice: A Guide for Pharmacists and www.rpsgb.org.uk). Data will be analysed by UniChem Professional Services in an anonymised encrypted form. No information that can identify either the patients or the GPs, involved in this service will be made available to any third party.
MethodologyGP Briefing
Following the training session, pharmacists will be required to brief their local GPs on the programme, discuss the referral criteria and agree the process for referral, within two weeks of their training date. A GP Briefing Pack is provided to facilitate this process.
Programme Process
A flow diagram of the programme process is included on Page 13.
The pharmacy will deliver the programme as follows:
1. Identify suitable patients as per inclusion and exclusion criteria
2. Provide prospective Patients with a programme Patient’s Information Leaflet
3. Once the patient has expressed an interest, obtain their written consent utilising the Patient’s Consent Form
4. Conduct a baseline assessment with the patient, which includes completing the Patient’s Assessment Form and measuring the following monitoring parameters (as appropriate for the person):
§ For ALL the patients recruited, record BMI, Waist Circumference, & Blood Pressure
§ For Type-II Diabetes patients – Conduct HbA1c, Blood Pressure and Total Cholesterol measurements
§ For Hypertensive patients – Conduct Blood Pressure measurement
§ For patients with Hyperlipidaemia – Conduct Fasting Total Cholesterol
5. Document the outcome of the baseline assessment onto the Patient Assessment Form
6. Provide the patient with relevant information leaflets, dependant upon the result
7. Provide the patient with a Weight Management Record Sheet, Appointment Card and “Your guide to maintaining healthy weight loss” & “Stock up your kitchen” Booklets
8. Set targets for diet plan and exercise. Aim for a 5% weight-loss overall for the programme duration
9. Refer to the GP Practice if any results fall outside the recommended guidelines as per Plymouth Teaching PCT recommendations.
10. Book the patient in for a follow-up assessment(s) as outlined in the table:
Action / Time Interval / Monitoring Parameter(s)Recruitment / 0 weeks / Weight, BMI, BP, Waist Measurement, TC, & HbA1c
1st Follow-up / 2 weeks (fortnightly) / Weight, BMI, BP & Waist Measurement
2nd Follow-up / 4 weeks (fortnightly) / Weight, BMI, BP & Waist Measurement
3rd Follow-up / 6 weeks (fortnightly) / Weight, BMI, BP & Waist Measurement
4th Follow-up / 8 weeks (fortnightly) / Weight, BMI, BP & Waist Measurement
5th Follow-up / 12 weeks (monthly) / Repeat recruitment measurements
6th Follow-up / 16 weeks (monthly) / Weight, BMI, BP & Waist Measurement
7th Follow-up / 20 weeks (monthly) / Repeat recruitment measurements
8th Follow-up / 24 weeks (monthly) / Weight, BMI, BP & Waist Measurement
9th Follow-up / 28 weeks (monthly) / Weight, BMI, BP & Waist Measurement
10th Follow-up / 32 weeks (monthly) / Repeat recruitment measurements
11th Follow-up / 36 weeks (monthly) / Weight, BMI, BP & Waist Measurement
For a variety of local exercise opportunities that might help your patient look on www.plymouthguild.org.uk then click on ‘Active for Life’ at the top of the list on the left side of the page. Alternatively phone Justin Ranger , Plymouth Guild, Ernest English House, Buckwell St, Plymouth PL1 2DA tel 01752 201766/ Fax 01752 202214’
Role of Pharmacy Support Staff
The pharmacy support staff plays a crucial role in the recruitment of patients (e.g. the provision of the information leaflet and explaining the service, prior to screening test) and assisting in the management of documentation. Once documented that they have been appropriately trained and are competent; support staff will be able to assist in testing under the supervision of a trained pharmacist. Please note: The PCT may request to see copies of the training records for support staff.
Pharmacist Intervention & Referral CriteriaThe results of the various monitoring parameters and referral trigger points are summarised in the table below.
In general, patients will be responsible for making their own appointment with their practice. Urgent referrals will be made by telephone by the pharmacist to the relevant practice and followed up by documentation.
Monitoring Parameter / Optimum Value / ReferralTotal Cholesterol / <5mmol/L / To be agreed with local GP practice
Blood Pressure (Refer to MHRA guidelines on Pg 26) / 140/85mmHg / As above
For patients with diabetes, 130/80mmHg
HbA1c / 6.5% - 7.5%
Waist Measurement / Male < 102cm / As above
Female < 88cm
The above parameters follow NICE recommended guidelines. Individual patient parameters may vary depending on guidance provided by the patient’s GP, and should be borne in mind when providing feedback to the patient. The pharmacist should exercise their professional discretion when interpreting test results.
Data FlowData from the monitoring parameter tests are captured on the Patient Assessment Form (sample provided on Page 30) together with the result of any diagnostic test performed in the GP surgery. Patients will be provided with a record of the outcomes by the pharmacists.
Green copies of the Patient Assessment Form documenting test(s) results or suitable annotations should be returned to UniChem Professional Services at the end of each month. White copies should be given to the patient and Yellow copies are to be retained in the pharmacy for 7 years.