In 2003 the Department of Health and Social Services and Public Safety Northern Ireland (DHSSPSNI) requested trusts to submit proposals for innovative ways of delivering nursing services based on the models of nursing described in its 2003 position paper Strategic Direction of Community Nursing in NI.
Homefirst Comunity Trust was successful in its bid, designed to test the model of First Contact care and elements of chronic disease management, which fitted within the DHSSPSNI model.
The proposal directed that care should be delivered in the heart of the community by an appropriately skilled nurse practitioner/prescriber using advanced skills of diagnosis and treatment. There would be a greater emphasis on disease prevention by addressing lifestyles and behaviours, to give greater choice and support in behaviour/lifestyle change in order to improve their health.
This was a unique health approach and at the time there was no comparable service across NI. From the start of the walk-in clinic and health promotion sessions extensive consultation with local residents and robust audit procedures are in place and the clinic has been well accepted by the community.
Glenfield walk-in clinic started in October 2004 and offers local residents in Carrickfergus greater choice in healthcare delivery while complementing care given by local GP practices.
The clinic is based in a community centre in the heart of an estate and involvement with the residents defined the services that are offered. A base line needs assessment, a focus group and qualitative questionnaires targeted at users of the service was performed within the community and one service requested was weight management.
Health promotion/education plays a huge part of healthcare delivery and the weekly weight clinic began on 10 January 2005. The average attendance is 25, with 50 being the most at one session. The success of the weight clinic has demonstrated a 58% reduction in weight overall and the first year showed a weight loss of 275kg in total.
To reward patients for their hard work in this weight loss the community association (where the clinic is based) applied for a grant towards purchasing reflexology vouchers and these were presented to those with weight loss of 5-15kg.
Obesity is an increasing health problem in NI, with at least 17% of men and 20% of women classed as clinically obese. Over the past 20 years the average number of calories consumed fell slightly, though more of these calories were eaten as fat and refined sugar. The average amount of exercise fell reflecting our more sedentary lifestyles.
Weight reduction even of modest proportions can provide an improvement in health (SIGN, 1996). Too often GPs set goals with patients that are unrealistic, so patients become disillusioned and gain weight.
The Glenfield weight management programme looks at weight holistically. Initial assessment is made on one-to-one basis and includes recording personal details, health history/medication and subjective history followed by objective, weight/height/ blood pressure, waist measurement, bloods and lipid profile, random glucose and thyroid function tests.
Venepuncture is not performed on all patients, only those whose GPs have given consent for, as patients attend the clinic from a 5-10 mile radius. Diet history includes past history of dieting, readiness to change and barriers to this change. Current eating habits/diet and beliefs about food and weight loss are discussed.
Levels of activity are important as a lot of patients feel unable to exercise, so this must be explored and advice given. Motivation is a huge factor in weight loss and it is important to encourage patients. Many patients in this disadvantaged locality are depressed, which can lead to weight gain. Discussions are one-to-one and also in group sessions, and include the benefits of weight loss and goals.
Individual eating plans with modifiable eating habits and hunger scores (0=not hungry and 10=ravenous) must be discussed. Subsequent sessions include discussion of weight or body shape changes.
To help, encourage and also educate patients attending the weight clinic other professionals have given presentations relating to functional exercise, especially to those who feel they are unable to perform any exercise, and simple chair exercises are encouraged and demonstrated.
Referral to the local leisure centre to a trained instructor for a period of 12 weeks has been very beneficial. Patients have maintained this programme and have reduced not only their weight, but also lipid profile and HBA1C relating to diabetic patients.
Some patients felt they were embarrassed to attend the leisure centre due to their weight, so a walking group was established. Pedometers were issued and patients were greatly encouraged by recording their steps. To augment this simple exercise I applied to the Health Promotion Agency for funding to take the walking group for an outing to visit another community group who hoped to replicate the services we offered. A bus was arranged and we set off to the beautiful north coast 50 miles away, met the local mayor and community group and had our walk around the seaside resort.
Sessions have also been facilitated by a clinical psychologist, who demonstrated that weight loss can be maintained. This encouraged patients, as they felt someone understood their weight dilemmas without judging them.
Patients are now referred to the weight programme from other health professionals such as local GPs. A record of the patient?s weight loss or attendance is forwarded to the relevant GP every six months (with the patient?s consent) and the practice can update the patient?s medical records and also assists with the GMS contract information/points.
Anti-obesity medication has been prescribed for some patients and I can prescribe as a supplementary prescriber. However, patients must still be motivated to lose weight to gain the benefit from medication.
Weight management is an ongoing problem facing all health professionals and it is important to be aware of the combination of problems patients have in their personal life and work life.
To date the weight management programme offered at Glenfield walk-in Clinic has been very successful. No appointment is necessary and patients feel the personal service encourages and improves motivation. A variety of different advice leaflets or low fat/calorie menus are on display and small amounts of verbal information is given at each attendance.
Since the programme started it has shown that healthy eating and simple walking/exercise will aid weight loss, and I feel there is no such thing as junk food, just junk diets.
When creating such schemes it is important to understand patient?s health beliefs and to recognise their understanding of what health professionals advise them to do.
The most important aspect of weight loss is not telling them to lose weight but to assist and educate them to be successful at their own pace.