Change 4 Life by nyut545e2


									Obesity Market Development
Event – The Strategic Context
     for NHS Mid Essex

                                 Jane Richards
    Assistant Director of Public Health (Health
           Improvement & Health Inequalities)
The Vision

“Our vision is of healthy communities where
  everyone is able to make healthy lifestyle
  choices and get the health and well being
  services they need”

                       Delivering Healthy Communities
              NHS Mid Essex Strategic Plan 2009 -2014
Strategic Context

Investing where we can achieve greatest improvement
in your health and targeting marginalised groups

• Improve access to health and well being services for
• Support people in living a healthy lifestyle
• Improve the health of the poorest in our communities
  and marginalised groups
Commissioning for Health and
Well Being
• Commissioning programmes to support behaviour
   • Stop Smoking & Tobacco Control

   • Obesity & Weight Management
   • Community Well Being (Including Health Trainers)
Redesign and commissioning
health improvement services
  • To improve the quantity of choice
  • To promote and inform the community of
    services available to them
  • To provide people with information and
    access to services that will lead to a
    sustained behaviour change to enable them
    to make healthy lifestyle choices
The QIPP agenda

• Quality – seeking to procure high quality outcome based service
  delivery model which meets the needs of our population
• Innovation – commissioning for outcomes resulting in opportunity
  for providers to demonstrate how this can be achieved using
  innovative models with a demonstrable evidence base
• Productivity – pathway is designed to maximise productivity at
  each stage in order to achieve highest level of return on investment
• Prevention – critical part of the prevention agenda with strong links
  to other areas of service delivery e.g. vascular health checks
Service Descriptions

   NHS Mid-Essex
   Obesity Care Pathway

• It is the intention of NHS Mid Essex to create a
  sustainable healthy weight infrastructure
• Integrated and tiered model of care designed
  specifically to meet the needs of the local population
• The framework will adopt a comprehensive life-course
  approach, encompassing pre-conception and antenatal
  phases through to adulthood and later life
Where have we come from

• Healthy Weight: Social          •   County JSNA
  Marketing Insight               •   Vital Signs
• Directions, 2008/09
                                  •   NCMP
• Healthy Weight; Healthy Lives
  Strategy, 2008                  •   PSA 12
• Foresight Report, 2007          •   NI sets: -
• Local gap analysis, 2008/09          - 53: Breastfeeding rates
• Regional Support Team                - 55: Obesity Reception
• NHS Mid Essex Strategic Plan         - 56: Obesity Year 6
  & 10 Commitments
                                       - 198: Travelling to School
• LAA 2
What is the current status of
local provision
• Contracts with commercial     • Group based adult weight
  sector, Central Essex           management service
  Community Services and Mid
  Essex Hospital Trust          • Commercial self-help adult
• Range of community-based        weight management
  prevention and treatment      • Adult Health Trainer service
  weight management and         • Brief and Opportunistic training
  weight loss services:           for key workers
• Breastfeeding Peer Support    • Dietetics and dietetic clinics
                                  (working out GP practices)
• Early Years multi-component
  prevention programme          • Pharmacotherapy
• 7 -13 multi-component         • Bariatric surgery
  treatment programme
   What do we know
• Existing care pathway are disparate and uncoordinated
• The weight management and obesity domain encompass a range of
  interventions; direct and in-direct services, spanning multiple directorates
• Anti-Obesity prescription costs have double in the last year
• A steady increase in the number of patients referred into bariatric
  surgery over the past three years
• We are not doing enough for patients with the most complex needs
• One size does not fit all
• Conversion to service engagement to programme completion is low
• Maintenance and follow up is traditionally very low
• GP‟s and other HCPs are confused as to what services they can/should
  safely refer patients into
What works: The Evidence

• Obesity is the second most             • Department of Health
  common preventable cause of                • C4L insights/market
  death after smoking in Britain today          segmentation
  and is responsible for more than       • National Obesity Observatory
  9,000 premature deaths per year in
  England.                                   • SEF/ Treating adult obesity
• Costs to the NHS, currently £4.2bn            through lifestyle change
  a year, are predicted to more than            interventions, 2009/ Treating
  double by 2050                                childhood obesity through
                                                lifestyle change interventions,
• £85.1m:Estimated cost to NHS Mid              2010
  Essex for diseases related to          • Rotherham Model
  overweight and obesity for 2010
• Healthy Weight; Healthy Lives              • Maryon-Davis
• Choosing Health 2004: invest in        • Middlesbrough, Redcar &
  prevention/intervention for long         Cleveland
  term savings                           • Addenbrookes Hospital
• NICE Guidance                          • West Sussex
  What do we want
• Create a patient-led, sustainable      • Outcomes rather than activity
  healthy weight infrastructure          • Better identification and
• Target resources on community            assessment* of „at risk‟ patients
  based interventions that               • Better whole population access
  encompass one, some or all of the        to facilitated behaviour change
  following (depending on patient          & lifestyle modification
  assessment and RTC): dietary           • Reduce the population trend in
  advice/ physical activity/ behaviour     growth from individuals moving
  change                                   from a healthy weight to
• Improved patient choice, journey         overweight and overweight to
  and experience                           obesity
• Confident and supported workforce
• Improve Early Years nutrition
• Up skill and enable families from
  the most deprived communities to
  live healthier lifestyles
Obesity Model
                                            TIER 4 Acute:
                                           Bariatric Surgery

                            TIER 3 Specialist: Specialist MDT Obesity Service
                                              IAPT; Dietetics

                    TIER 2 Community: Targeted weight management and treatment
                programmes; Family-led: one to one/ group based; Commercial programmes;

     TIER 1 Gyms, GP‟s; Practice Nurses; Health/Vascular & Planning, Built Environment, Play,
     OutdoorPrimary:Leisure & Green Spaces, TransportCheck Programme; Community Pharmacists;
           Dentists; Health Trainers; Health Visitors; Midwives; School Nurses; Children‟s Centers;
School-based initiatives, NCMP, Food Cooperatives, Change4Life; Start4Life; Healthy Start; 5-A-Day
                   Early Years programme; Infant Feeding; Breastfeeding Peer Supporters
Tier 1          Tier 2   Tier 3         Tier 4

Loretta Sollars
Essex County Council
Tier 2: Community Weight
Management Services
Service Description
Service Overview

• Support those with greatest       • To provide local service
  need to access an appropriate       provision that is timely and
  service                             responsive
• Delivered in a community          • Ongoing engagement with
                                      patient groups
  setting with ease of access
                                    • Provide effective and efficient
• Strong clinical governance &        treatment service(s)
  supervision                       • Reduce the prevalence of
• Equitable and accessible            obesity in targeted populations
• Offer a high quality service        according to risk and level of
  based on the best available         need
• Support patients in maintaining
  and managing a healthy
  weight/ weight loss over an
  agreed duration
Early Years
•   2–4                               • Infant feeding/ activity time
•   Family-centred                      “minimise sedentary activities
•   Multi-component                     during play time, and provide
•   Targets „at risk‟ families: For     regular opportunities for enjoyable
    example, Parental obesity as        active play and structured physical
    key factor‟                         activity sessions”
•   Marketing to „Pressurised‟/       • Works closely with Children‟s
    „Inexperienced‟/ „Treaters‟         Centres and Health Visitors
    families                            “work across the range of Early
    (C4L Market segmentation)           Years settings to implement
                                        Department for Education and
•   Focuses on behavioural goals        Skills, Food Standards Agency
    (C4L behaviours)                    and Caroline Walker Trust
•   One year follow-up post             guidance on food procurement and
    intervention                        healthy catering”
•   Evaluation to incorporate
    parent or carer pre & post
    weight measures
  Children & Families
• 5 – 13                                • Target NCMP referrals
• 91st – 98th centile                   • Healthy Schools and School
• Family-centred                          Nurse interdependencies
  “Interventions for childhood          • More than one service option is
  overweight and obesity should           required
  address lifestyle within the family   • Treatment programme
  and in social settings”               • Weight loss KPI: Programme
• Multi-component                         evaluation should aim to
  “Multi-component interventions          demonstrate a target weight
  are the treatment of choice.            loss
  Weight management                     • Incorporates behavioural goals
  programmes should include               (C4L behaviours)
  behaviour change strategies to        • One year follow and
  increase people‟s physical              maintenance post intervention
  activity levels or decrease
  inactivity, improve eating            • Marketed appropriately at
  behaviour and the quality of the        target population
  person‟s diet and reduce energy
Teenage & Adolescents Pilot

• 13 – 16
• Overweight or obese cohort
• Group based or one to one
• Multi-component
• Weight loss KPI: Programme evaluation should aim to demonstrate
  a target weight loss
• Up to one year follow and maintenance post intervention
    Outcome Measures
•   The success of interventions targeting children will be assessed in the context of
    the target population. Indeed some interventions may aim to support children and
    young people to „grow into their weight‟ (which may of course involve maintaining
    their weight over time as they grow taller) rather than lose weight
•   Quality of life and behaviour change indicators
•   All programmes should evaluate cost effectiveness and sustainability.
•   All programmes should be thoroughly evaluated. Good quality evaluations will
    strengthen the evidence base and support effective commissioning in the future.
    The Department of Health recommends that interventions are evaluated using the
    NOO Standard Evaluation Framework for weight management interventions:
•   Programmes should align with government messages such as „5 A DAY‟ and the
    recommendation for 60 minutes of daily moderate-vigorous activity among
•   Programmes should aim to be enjoyable, engaging and easy for the target
    audience to access
Community adult weight
•   16>
•   Overweight or obese cohort
•   Group based or one to one
•   Single and Multi-component
•   More than one service option is required
•   Weight loss KPI: Programme evaluation should aim to demonstrate
    a target weight loss
Commercial adult weight
management programmes
• Self-help, commercial, or             • use a balanced, healthy-eating
  community weight management             approach
  programmes should follow best         • recommend regular physical
  practice, by:                           activity (particularly activities that
• helping people assess their weight      can be part of daily life, such as
  and decide on a realistic healthy       brisk walking and gardening) and
  target weight (people should            offer practical, safe advice about
  usually aim to lose 5–10% of their      being more active including some
  original weight)                        behaviour-change techniques,
• aim for a maximum weekly weight         such as keeping a diary and
  loss of 0.5–1 kg                        advice on how to cope with
• focus on long-term lifestyle            „lapses‟ and „high-risk‟ situations
  changes rather than a short-term,     • recommend and/or providing
  quick-fix approach                      ongoing support
• are multi-component, addressing       • on-going monitoring of patients
  both diet and activity, and offer a     and provision of support and care
  variety of approaches
    Outcome measures
•   The key outcome measure for weight management interventions is a reduction in
    overweight or obesity, usually defined as body mass index (BMI). As a person‟s height is
    unlikely to change, the key measure is body weight
•   It is important to note that significant health benefits can be achieved from modest
    amounts of weight loss. Realistic targets for weight loss for adults are usually seen to be
    a maximum weekly weight loss of 0.5–1 kg, and a total loss of 5–10% of original body
    weight over the period of the intervention
•   Weight loss targets should be related to starting weight; eg people with BMI under 40
    may be encouraged to aim for a loss of 5% body weight while those with BMI >40 might
    aim for >10%
•   Interventions should stress that physical activity is important even if participants do not
    lose weight, because of the other health benefits physical activity can bring, such as
    reduced risk of type 2 diabetes and cardiovascular disease
•   Similarly, people should be encouraged to improve their diet even if they do not lose
    weight, because there are significant other health benefits such as reduced risk of
   Additional Recommendations:
• All programmes should be thoroughly       • Evidence from the NICE guidance
  evaluated. Good quality evaluations         on behaviour change is also
  will strengthen the evidence base and       relevant for lifestyle interventions to
  support effective commissioning in          prevent obesity. The guidance
  the future. The Department of Health        suggests that effectiveness is
  recommends that interventions are           enhanced when people:
  evaluated using the NOO Standard          • Understand the likely impact of
  Evaluation Framework for weight             their behaviour on their health
  management interventions. Validated       • Feel positive/optimistic about
  measurement methods should be               changing their behaviour
  used wherever possible.
• Programmes should be aligned with         • Make a personal commitment to
  government messages such as „5 A            change
  DAY‟, the CMO‟s recommendation for        • Set goals to undertake specific
  physical activity, and social marketing     actions over a specified time
  campaigns such as Change4Life.            • Plan changes in terms of easy
• Programmes should aim to be                 steps
  enjoyable, engaging and easy for the      • Plan for events or situations that
  target audience to access.                  might get in the way of change
• Share their behaviour change goals
  with others
Mandy Elder
Senior Commissioning Manager
East of England Specialised
Commissioning Group
Where are we now?

•   Bariatric surgery commissioned through the SCG
•   Restricted clinical criteria – Not in line with NICE CG43
•   Over 300 bariatric surgery episodes in 2009/10
•   Cost £2.1 million in 2009/10
What is T3?

•   It has a multidisciplinary team approach
•   Obesity Specialist Nurses (OSNs),
•   Dietetics input for complex dietary needs
•   Clinician with a specialist interest in obesity
•   Talking therapists for psychological and counselling input
•   Physical activity specialist with on-site gym facilities
•   Specialist weighing and measuring equipment,
•   Group work and cooking skills/education
•   Access to commissioned bariatric surgeons
•   Access to secondary care specialists if appropriate (through the
Why do we need T3?

•   Improve the patient pathway – gives the patient options
•   Potential to reduce pressure on acute surgical services
•   Potential to reduce prescribing costs
•   Potential to reduce “revolving door” patients
•   Potential to allow changes to the existing criteria…longer term
Tier 3: Specialist Weight
Management Service
Service Description
In 2002, the Department of Health issued a definition as to
what should constitute specialist morbid obesity services
for adults and children. It recommended an integral
management approach for patients aimed at weight loss
and weight maintenance. Programmes should be drawn up
by a multidisciplinary team and may include some or all of
the following: weight loss goals, diet, behaviour
management, physical activity, drug treatment and bariatric

•   A specialist weight management service will provide a multi component
    treatment option which could provide significant outcomes for individual
•   Many patients fail to attend for follow up and require significantly more
    support in the local area lending support to the idea of a locally accessible
    Specialist Weight Management Service (Harper, Madan, Ternovits et al
•   In some cases interventions which induce weight loss prior to surgery, and
    support weight loss and maintenance post surgically have been shown to
    be more effective than surgery alone (Alger-Mayer, Polimeni , Malone
    2008; Mathus-Vliegen 2007; Ali, Baucom-Pro, Broderick-Villa et al 2007;
    Steffen, Potoczna, Bieri et al 2009)
•   Reduction in the growth in numbers of bariatric surgical procedures deliver
    cost savings through appropriate interventions both before and after
    bariatric surgery
•   Local education & training for obesity management
•   Development of local capacity
•   A more sustainable weight management solution
T3 Pilot

• To be a cost effective service with the capacity to treat a minimum of
  4% of the potential patients per annum with obesity levels 2 & 3

• Any specialist setting should be equipped for treating people who
  are severely obese. Eg, special seating and adequate weighing and
  monitoring equipment
    Training, Marketing and SPE
•   Single Point of Entry refers to a central gateway to Tiers 1 & 2 Weight
    Management Services (inc Health Trainers) with the aim of streamlining the
    referral process
•   Initial focuses to target identified GP Practice engagement
•   Scope to extend the service to targeted Community settings; and domain to
    incorporate broader elements of Health & Wellbeing Services. Eg Healthy Walks;
    Exercise Referral; Cookery programmes
•   Reduce practice-based uncertainty regarding onward referrals
•   Free-up patient consultation time
•   Improved easy access on to the care pathway
•   Primary function of the SPE service is to perform:
      - Patient assessment
      - Programme booking
      - Onward referral
      - Distribution of information and advice
      - Maintain effective lines of communication with the Primary referring agency
      - Periodical patient follow-up
Training & Marketing

•   Who‟s responsibility is recruitment?
•   How will you maximise routine patient assessment opportunities?
•   How can you enhance the core function of Key workers?
•   How will you ensure the intervention is targeted appropriately?
Adrian Coggins
NHS West Essex
Market Development/Service Redesign Event


           Procurement Lead for NHS
Principles of NHS Procurement

 It is NHS policy to follow the key principles of best
 practice procurement :

 •   Transparency
 •   Proportionality
 •   Non-discrimination
 •   Equality of treatment
The Procurement Process
Steps completed so far:

                                  PQQ      ITT    AWARD
ADVERT                MOI                                 Commence

                                Consider   PQQ/            Service
ADVERT                    MOI                     AWARD
                                 options    ITT           Commence
The Procurement Process Options

•   PQQ and ITT together – similar timescale to advertised
•   One contract or „lots‟
•   A Framework Agreement
•   Any Willing Provider
Contracting Options

Single contract for whole    Opportunity for small
pathway „managed service     providers to network with
provider‟                    potential lead contractors to
                             form „co-operative‟ bids

Contracts for individual     Opportunities for small
elements of the pathway as   providers to be contractors,
„lots‟                       large number of contracts
                             for the PCT to manage
Collaboration across Essex

•   Essex County Council working with the PCTs but not part of this

•   Essex PCTs to decide soon who is part of the procurement

•   Possibility for „phased‟ start to contracts
Next Steps

• We need provider input

• PCTs need to make decisions on the procurement route and scope

• Mid Essex will be progressing a procurement and will keep in touch
  with providers on progress of decisions and timescales

Procurement team for NHS Mid Essex 01245 398720 01245 459412
Questions & Answers

To top