A Healthier Future: analysis of consultation responses

9. Supported weight management services & other interventions (Qs 8-9)

9.1 The consultation paper set out current estimates of the prevalence and incidence of type 2 diabetes in Scotland, and described the impacts of this condition on peoples’ lives, on the health service, and on the economy. It went on to describe the Scottish Government’s plan to invest £42m over five years to establish supported weight management interventions for people with, or at risk of developing type 2 diabetes. The consultation paper also covered proposals to support the delivery and development of (wider) healthy living interventions as treatments through the NHS and third sector.

9.2 Respondents were asked for their views on the implementation arrangements for the weight management service (at Question 8) and for their views on support for healthy living interventions – including the quality and referral arrangements for weight management programmes – (at Question 9). There was substantial overlap in the comments at these questions, and they have therefore have been considered together.

Question 8: How do you think a supported weight management service should be implemented for people with, or at risk of developing, type 2 diabetes – in particular, the referral route to treatment?

Question 9: Do you think any further or different action on healthy living interventions is required? Please explain your answer.

9.3 Altogether 260 respondents (108 organisations and 152 individuals) provided comments at Question 8, and 238 respondents (115 organisations and 123 individuals) provided comments at Question 9. Very few comments were offered by private sector and business organisations in relation to these questions. By contrast, almost all public sector health organisations, local authorities and partnership bodies, public health professional groups and weight management organisations, and around half of third sector organisations, research organisations, sports bodies, and other professional bodies provided comments.

9.4 The comments covered a wide range of issues, both general and specific. Detailed responses, including evidence about efficacy and effectiveness, were offered in relation to specific weight management programmes. Most often these comments came from public health or NHS organisations, or commercial weight management organisations. However, a small number of well-informed individuals also provided detailed evidence and commentary.

9.5 The main themes raised in these comments are discussed below under the headings of (i) coverage and targeting, (ii) referral routes, (iii) the nature and content of weight management programmes, and (iv) the broader context.

Coverage and targeting

9.6 Respondents from all sectors and groups welcomed the funding commitment from the Scottish Government for supported weight management programmes. There was a widespread view that substantial investment was needed in this area, and that there was wide variation in the availability (and potentially the quality) of the programmes currently available across Scotland. There was a general assumption that this funding would be (initially) directed into the NHS. However, respondents also emphasised that (some of) the funding would subsequently be directed onwards into other organisations and sectors, in particular through the use of ‘social prescribing’ and through referrals to commercial weight management programmes. ^[31]

9.7 The following issues relating to coverage and targeting were raised by all groups who responded to this question:

• It was not clear why these programmes were to be targeted only at those with – or at risk of developing – type 2 diabetes; the issues of obesity and overweight extend beyond these subgroups. These programmes should be available to anyone – and everyone – who needed support.
• Offering these programmes only to people who were already diagnosed, or who were identified as being at risk, meant the investment would be focused on treatment (of the individual) and not on prevention (at a population health level). This was thought to run counter to the government’s commitment to a preventative approach. Respondents therefore thought that this investment would have to go hand-in-hand with investment in more ‘upstream’ interventions.

9.8 In addition, respondents from the NHS and from public health organisations asked how those ‘at risk of developing type 2 diabetes’ would be identified as the UK National Screening Committee does not currently recommend population screening for type 2 diabetes. ^[32]

9.9 The recruitment to and uptake of programmes was also discussed by a wide range of respondents, particularly in relation to groups where uptake was historically low (e.g. men, people with long-term conditions, black and minority ethnic groups, parents with young children, adolescents, and more deprived socio-economic groups). In addition, there were suggestions that certain groups should be specifically targeted (e.g. people with long-term conditions, adolescents, pre-conceptual women, pregnant women, and cancer survivors). The importance of providing accessible, age-specific, socially and culturally appropriate services which were free at the point of delivery (e.g. if referral to an exercise class was part of the programme this would have to be funded), was emphasised by a wide range of individual and organisational respondents, especially in the context of not increasing health inequalities.

Referral routes

9.10 Respondents discussed referral mechanisms. Both individual and organisational respondents were most familiar with referral by GPs. However, there appeared to be differing opinions about whether the current GP referral system was working well. Consultation respondents were supportive of current GP referral arrangements and pointed to the trust between patients and their GPs, and to evidence which suggests that patients are willing to act upon advice given to them by their GPs. However, attendees at the ScotPHN engagement events suggested that the current GP referral system was too complex and it was thought there may be some scope to improve this through the new GP contract.

9.11 Thus, while there was general support for a GP referral system, there was also widespread support for a broader range of possibilities in relation to referral to a supported weight management programme. Specifically, respondents thought such services should be available by self-referral, as well as through referral by a range of other professionals including:

• Health care professionals within a primary care setting (pharmacists, community nurses, specialist diabetes nurses, mental health nurses, allied health professionals, etc.)
• Health care professionals within a secondary care setting (who might see someone for weight-related co-morbidities)
• Employers
• Other professionals (social workers, advocates, leisure centres, third sector, etc.).

9.12 This suggestion of a wider range of possibilities for referral pathways was often accompanied by a request for (i) more investment in the training of both health care professionals and non-health care professionals so that they are better equipped to provide advice and guidance on healthy weight; and (ii) more ‘joined up’ working across agencies in the public, private and voluntary sectors to ensure that available resources were deployed to best effect.

9.13 The NICE Guideline on population and community-level interventions for the prevention of type 2 diabetes (which covers, inter alia, referral pathways) was mentioned as a positive approach, mainly by NHS and partnership bodies. ^[33] More broadly, respondents from all sectors emphasised the importance of developing referral pathways that are simple and ‘streamlined’ so that any barriers to access would be reduced.

9.14 There was specific comment from two organisations offering weight management programmes that existing referral processes in some areas are not currently working as they should; these organisations had capacity to provide a service to many more people than were currently being referred.

Nature and content of weight management programmes

9.15 There was a substantial amount of comment on what a weight management programme should include, much of it – particularly from those directly involved in delivering programmes – discussing the (emerging) research evidence. The importance of programmes being evidence based, and proven to be effective, was emphasised by all groups. Respondents across a variety of organisational groups described the success of programmes currently up and running in Scotland.

9.16 There was a general view that programmes needed to take a broad and holistic view of the support required, and therefore should (i) cover both diet and physical activity; (ii) address self-management and behaviour change; (iii) provide psychological support if required; and (iv) include education about healthy eating and meal planning, and the development of cookery skills.

9.17 There was widespread support for the involvement in weight management of organisations and resources beyond the health sector. Community-led programmes of all kinds, and the involvement of the third sector in general, were thought to be vital. Respondents talked about building on existing arrangements for ‘social prescribing’ and highlighted the benefits of walking groups, exercise classes, etc., for those across the entire spectrum of overweight and obesity – both in relation to weight loss and weight maintenance.

The broader context

9.18 Some respondents – particularly individuals with personal experience of weight management services – focused on the importance of the broader context. They thought weight management programmes: should avoid ‘simplistic messages about eating less and exercising more’; should address psychological wellbeing and mental health issues; and should not stigmatise or ‘blame’ the obese person. Related to this, a range of individuals and organisations (particularly from the public and third sectors) thought programmes should focus on wellbeing more generally, with weight loss being seen as a secondary outcome.

9.19 Both individual and organisational respondents (especially from the public health, public sector and third sectors) called for more investment – and longer term investment – in programmes that go wider than weight management to tackle issues of healthy living, community cohesion and social isolation. These respondents described local programmes and community-based initiatives which they were involved in, or knew about, and which they thought should be sustained and / or rolled out on a wider basis. Respondents frequently said that there was evidence that these initiatives were effective, and some cited published evidence to that effect. Many of the specific examples mentioned focused on (i) physical activity, (ii) community food initiatives (including cooking classes), and (iii) family based programmes.

Other points

9.20 Other relevant issues raised by respondents were that:

• The duration of a weight management programme was important. Evidence was cited that many current weight management programmes are not long enough, and respondents advocated programmes that last at least one year.
• There needs to be a strong focus on maintaining weight loss (weight-regain prevention) as well as on weight loss itself. This points towards programmes of a longer duration.
• Offering someone access to a programme at the point at which they are diagnosed with type 2 diabetes might provide the best opportunity to encourage engagement / participation.
• Local and national campaigns to alert people to the dangers of obesity could be beneficial. In addition, technology, apps and social media could be used to deliver online messages and advice.