I write in response to your request for information in relation to money spent on weight management services in NHS Lothian.

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1 Lothian NHS Board = Waverley Gate 2-4 Waterloo Place Edinburgh EH1 3EG = Telephone: Date: 31/12/2015 Our Ref: 563 Enquiries to : Bryony Pillath Extension: Direct Line: bryony.pillath@nhslothian.scot.nhs.uk Dear FREEDOM OF INFORMATION WEIGHT MANAGEMENT I write in response to your request for information in relation to money spent on weight management services in NHS Lothian. I have been provided with information to help answer your request by Ms Fiona Huffer, Head of Dietetics, NHS Lothian. Question: 1. If possible, I would like details of expenditure on weight management services in your health board area over the past three years. 2. Can you provide a breakdown of where/how this money was spent? For example, can you outline how much was spent on weight management courses, gastric band surgery, gastric sleeve surgery etc over each of the past three years? 3. In addition, can you provide details for next year s spending on weight management services? Again, can you please outline where/how this money will be spent? Answer: The costs for bariatric surgical procedures are given in the table below. This includes gastric bypass and gastric sleeves and pre, peri and post-operative care for life long patients. The current spending prediction for bariatric surgical procedures is based on undergoing 72 procedures per year. Cost bariatric surgical procedures, NHS Lothian Year Cost 2011/12 1,049, /13 1,024, /14 1,083,960 In addition to bariatric surgery, NHS Lothian provides a weight management service for a number of patient groups. These services are described in the attached report.

2 563 Weight Management December 2015 Tier 2 weight management services are funded at a total of 76,010 per year. It is not possible to separate the costs of tier 3 and 4 weight management services from the Community Dietetics budget as dieticians working in the service also treat a range of clinical conditions within the primary care service. Question: 4. Can you provide figures for any target numbers relating to referrals for gastric bypasses / bands / sleeves, both in the past three years and in the coming year? Answer: The spending on bariatric surgery in NHS Lothian is focussed on 72 surgical procedures per year. This is the proportion recommended in the 2012 National Planning Forum guidance. The 72 procedures include gastric bypass and gastric sleeves; the number of each procedure fluctuates dependent on patients and medical comorbidities. I hope the information provided helps with your request. If you are unhappy with our response to your request, you do have the right to request us to review it. Your request should be made within 40 working days of receipt of this letter, and we will reply within 20 working days of receipt. If our decision is unchanged following a review and you remain dissatisfied with this, you then have the right to make a formal complaint to the Scottish Information Commissioner. If you require a review of our decision to be carried out, please write to the FOI Reviewer at the address at the head of this letter. The review will be undertaken by a Reviewer who was not involved in the original decision-making process. FOI responses (subject to redaction of personal information) may appear on NHS Lothian s Freedom of Information website at: Yours sincerely ALAN BOYTER Director of Human Resources and Organisational Development Cc: Chief Executive Page 2 of 2

3 December 2015 Weight Management Provision in Lothian Background The NHS Lothian Weight Management Service is responsible for the development and delivery of all medically-referred treatment programmes for adult obesity in NHSL. The SIGN guideline 115: Management of Obesity is the key clinical document used to inform and shape service provision. This document makes the following 2 statements that NHSL have been working to achieve over the past 5 years since the service was established: Weight management programmes should include physical activity, dietary change and behavioural components Health boards should develop explicit care pathways offering a range of weight management interventions To this end, NHS Lothian developed its own strategic framework for management of overweight and obese adults using a tiered model approach to best meet the differing needs of patients. Tiers 3-5 of this framework have been in place since April 2010 following the redesign of community dietetic services. Service provision Tier 2: Get Moving with Counterweight Programme Three-year funding was allocated to each health board in 2012 from the Scottish Government Primary Prevention bundle and this was used in part in NHSL to establish a Tier 2 weight management service. The Scottish Government outcome framework for the prevention bundle allocation states: All NHS Boards must have a weight management programme in place aimed at Tier 2 and 3 of the Pathway for Obesity Management. Weight Management programmes should be designed to treat obese patients i.e. Body Mass Index (BMI)>30 kg/m 2. Tier 2 services should be delivered in primary care The Get Moving with Counterweight Tier 2 service is targeted at obese individuals over the age of 18 with a BMI greater than 30kg/m 2 who are committed to making lifestyle changes for weight loss. The programme is led by the NHS Lothian Weight Management Service but delivered in partnership with Edinburgh Leisure, West Lothian Council Health Improvement Team, Midlothian Council and East Lothian Council. Patients are referred by their GP practice and are then offered a place on a free 1 year group programme, consisting of 12 weekly sessions of physical activity and dietary advice using the evidence based Counterweight programme resources as an education tool. Participants are provided with all resources free of charge to keep following the initial 12 week programme, participants are followed up at 6, 9 and 12 months to support weight maintenance. Signposting to local physical activity groups and providers is given to encourage ongoing physical activity following completion of the programme. Service provision and outcomes Since the programme launch in 2013, there have been 1,853 referrals (as at 16 th December 2015) of which 60% chose to opt into and start the programme. Of those participants starting the group programme, 62% have gone on to fully complete it. Average weight loss 1

4 of those completing the programme is 3.4kg (2.52%). These outcomes are typical of other similar commercial programmes but without the cost to the individual. Weight loss percentage achieved is in line with widely published research in the area of obesity treatment. Tier 2: Football Fans in Training (FFIT) One year funding was awarded following a grant application to the Edinburgh & Lothian Health Foundation to pilot FFIT in NHSL is the first Health Board to work with the Scottish Professional Football League Trust (SPFLT) to offer this weight management programme for male participants only. Football Fans in Training is delivered in collaboration with the SPFLT at Hibernian, Heart of Midlothian and Livingston Football Clubs. Our groups are open to adult males over the age of 18 with a BMI>30kg/m 2. The programme is designed to target the `harder to reach` male population and provide a free, 13 week innovative weight loss and physical activity group intervention which also gives a behind the scenes look at what happens at their local football club. Service Provision and outcomes In 2015 to date, the programme has received 90 referrals, of which 30 have chosen to participate. Three groups have started, one at each club with a further 2 planned. The average weight loss of those completing the programme is 4.2% (5.1kg) with one participant losing 11.6% (19.3kg). New groups will start in the new year as we have funded 100 places. Tier 3: Get Lighter in Lothian This programme is permanently funded via the NHSL Nutrition and Dietetic budget and is delivered in primary care by community dietetic staff. The programme is targeted at the medically complex obese patient with a BMI>35kg/m 2 and a weight-related co-morbidity referred by their GP or medical practitioner. Patients are referred directly to the weight management service and triaged centrally to identify the most appropriate programme for them based on their weight, BMI and medical history. If Tier 3 is the most appropriate programme, patients are offered an initial 45 minute comprehensive assessment appointment with a dietitian in their local community where weight and dieting history as well as eating behaviour and motivation to change are discussed. These patients then proceed to a 14 week group programme (Get Lighter Core Programme) delivered by the dietitian that focuses on behaviour change for weight loss. This programme is augmented by the additional offer of a 12 week group physical activity course run by the weight management service Physiotherapist and Exercise Specialist who are trained to initially individually assess then tailor exercises for patients who will commonly have limited mobility. At the end of this programme, patients can proceed onto the 9 month weight loss/maintenance group programme where ongoing weight loss or maintenance of initial weight loss is supported. If an individual wishes to proceed forward to Weight Loss Surgery, or if they have complex issues that cannot be address in Tier 3 (e.g. emotional eating behaviour inhibiting success in group programme), they are referred onto Tier 4 for individual or more intensive support. 2

5 Service provision and outcomes The NHS L Weight Management Service receives an average of 1100 referrals per year to Tier 3 (based on figures April 2014 March 2015). Of these, 39% go on to start the group programme and 80% of these complete. Of those completing the programme, 41% achieve 3% or more weight loss, 24% achieve 5% or more. The service provides over 900 assessment appointments per year throughout Lothian and 40 groups with the maximum capacity to treat 600 patients through the 14 week core programme per year. The service also provides an individual programme for those patients unable to attend group due to being housebound or for reasons of sensory impairment. Currently approximately 60 1:1 programmes are run annually in Lothian. The physical activity group programme has the capacity for 170 patients per year. The weight loss maintenance programme runs groups throughout Lothian. Tier 4: Get Individual Advanced Weight Management (AVM) Those patients who have completed the Tier 3 Core Programme, have met weight loss targets and who wish to proceed to assessment for bariatric surgery are offered a place on the 3 month group programme Advanced Weight Management. In this group, patients attend 3 sessions over the 3 months and are given individual weight targets and advice that prepares patients for the necessary dietary, lifestyle and behaviour changes required for bariatric surgery. Provided weight loss targets are met, these patients are then presented at a multi-disciplinary team meeting with the Bariatric Surgery service for consideration of surgery. We are able to provide 100 places on this group and outcomes are currently being analysed. Specialist Dietetic 1:1 therapy Individual appointments are available with the specialist Dietitians in the Weight Management Service for those patients experiencing difficulties in achieving weight loss. There is a focus on motivational interviewing, cognitive behavioural therapy and behaviour change. Service provision There are 8 clinics run per month throughout Lothian providing an average of 65 appointments available per month. Counterweight Plus The Weight Management Service has commenced a pilot of the Counterweight Plus total diet replacement programme this year for 40 patients. Counterweight Plus is available for those patients who have completed the Tier 3 Core programme but have either experienced difficulties in weight loss or have a significant amount of weight to lose. Counterweight Plus is also a potential alternative to weight loss surgery. It is delivered by the specialist weight management Dietitians and involves intensive weekly appointments to begin with, tapering 3

6 down to fortnightly and monthly appointments as the programme progresses. Commitment is for 20 appointments per year per patient, so 800 appointments in total per annum. Weight Management Psychology Service The Weight Management Service has a dedicated psychologist ( part time). The role of the psychologist is to advise and support the team with the psychological aspects of obesity treatment which are essential to the provision of a safe and effective service. The psychologist provides an assessment service for disordered eating and any patient who has suspected disordered eating can be referred from Tier 3 assessment to the psychologist. If an eating disorder related to obesity is diagnosed, patients can be offered a course of 1:1 therapy with the psychologist or a place on our group treatment programme Eat. Think. Change. This group was developed by the weight management service and commenced in It is a new, innovative disordered eating group delivered in conjunction with a specialist dietitian. This group begins to address the treatment gap for patients with an eating disorder related to their obesity. The group has capacity for 15 patients in each 11 week programme. Outcomes are currently being collated for evaluation. Service provision 140 assessment appointments available per year 140 treatment appointments available per year 60 Eat, Think, Change places available per year. Total service costs for NHS Lothian Weight Management Service Tier 2 Scottish Government Prevention Funds 190,000 per year including Service Level Agreements with local authorities = 56,010 Football Fans In Training 20,000 Tier 3 Tier 3 not able to be disaggregate from NHS L Community Dietetic budget as these dietitians also treat a broad range of clinical conditions within the primary care service Tier 4 Specialist Weight Management Programme Tier 4 not able to disaggregate from NHS L Community Dietetic budget Bariatric Surgery Aspect of Service Bariatric surgery is provided by NHS Lothian at Royal Infirmary Edinburgh. 72 surgical procedures per year: Waiting time between surgical assessment and surgery 4-6 weeks All three surgical procedures are offered but generally sleeves and bypasses are viewed more favourably than the band. 4

7 No bands have been placed in the past 2 years Revision procedures included within the total numbers e.g. removal of failed bands and conversion to sleeve gastrectomy or bypass, revision of failed vertical banded gastroplasty Specialist theatre tables are used. Mulit Disciplinary Team comprises: Bariatric surgeons Bariatric Anaesthetists Clinical psychologist Bariatric specialist nurses Bariatric specialist dietitians Predicted Spending for year ahead The Weight Management Service anticipates funding for a further year as part of the Scottish Government Prevention Bundle the same allocation of funds which we would continue to run the service on the same budget and allocation. At this stage in the financial year, the 2016/2017 budget has not been confirmed. 5