The weight management enhanced service – is it worth signing up for?

GP partner and PCN lead Dr David Coleman explains the new weight management enhanced service requirements, the workload involved and how much it is likely to be worth to practices

The new enhanced service (ES) on weight management is one of two new services announced by NHS England this month, alongside the new long Covid ES. 

The service is a national specification with little scope for local amendments.

The specification itself notes that ‘in 2018/19 the majority of adults in England (63%) were overweight or obese with 26% of men and 29% of women considered obese or morbidly obese’, citing NHS Digital data. Obesity has proven to be a key risk factor for Covid as well, so it makes sense for NHS England to incentivise proactive work in this area.

What do practices need to do?

The ES begins on 1 July 2021 and will continue until 31 March 2022; practices wishing to participate must sign up before the end of 31 July 2021.

The overriding aim is to ‘ensure that everyone living with obesity is offered support for weight loss’. 

The specification defines obesity as a BMI ≥ 30, or ≥ 27.5 for those of Black, Asian and other minority ethnic groups.

There are two defined components to the ES:

1. Developing a supportive environment

• This focuses on: the education of staff, particularly in terms of how to talk about obesity; development of a protocol for the identification of new patients with obesity; and management/maintenance of the practice obesity register (by signing up, practices commit to restoring their obesity register to its 31 March 2020 level).

2. Patient support and referral

• This requires practices to assess all obese patients, both those on the register and those newly identified, to determine their readiness to engage with weight management services.  The outcome of these assessments must be recorded in the patient’s clinical record along with a recent BMI (within the last 12 months) and an offer of a referral to an appropriate weight management or specialist service.

How will practices be paid?

The specification indicates that the total £20 million funding envelope for the service won’t cover all patients on the register, so payment involves a referral allocation mechanism – essentially a cap on paid activity. This cap will be based on practices’ obesity registers as of March 31st 2020, and set initially at a minimum of one-third of the register. This allocation may be adjusted, depending on how many practices sign up for the ES. Any work beyond the referral limit with not be rewarded.

Practices will be entitled to claim £11.50 per referral – note that the payment is for the referral itself, not the assessment and offer of referral. Practices may find they need to assess a number of patients to generate a referral.

Commissioners may adjust referral allocations depending on performance – if a practice refers less than 40% of its allocation by the end of November, its allocation may be reduced and the funding shared out elsewhere. This will favour keen early adopters and the most organised practices. However, of concern it does seem to penalise those practices (and subsequently their patients) who may be struggling.

In addition, the specification notes that commissioners have the option to top up payments out of their own funds, to pay for additional referrals above the cap.

How much is it worth to a typical practice?

The funding available depends on your register.

If we take the example of a practice with 10,000 patients, 8,000 of whom are aged 18 and above, in an area where around 25% of adults – 2,000 – are obese. Assuming 35% of these are on the obesity register (this will vary for most practices, but I would be surprised if the number on the register is much above 50% of actual obese patients); that equates to 700 eligible patients. If the practice assesses every patient and one third are accepting of a referral, that amounts to 233 referrals. Assuming this remains within the practice’s referral allocation limit, the practice could claim 233 x £11.50 or £2,679.50.

In practice the acceptance rate will vary, depending on how enticing the local options are – a third would be quite an achievement. In the above practice, if only 20% patients were to accept the referral, the income would only be £1,610 – despite the same number of assessments and discussions taking place. And it could easily be lower still.

How much work is it?

The first component of the ES mentions staff training. While this isn’t linked to the payment/claims process, it will be worthwhile for clinicians to undertake training relevant to their scope of practice. It is a challenge to tailor discussions sensitively and without causing offence, and it appears this isn’t happening enough.

However, training alone won’t be enough. These discussions can’t be tackled with a quick 30 second monologue. I imagine nurses and HCAs would need at least a couple of minutes of extra time per consultation to cover this – a minimum of five minutes would seem optimal to do it well and secure the maximal number of referrals. This is quite an ask for primary care, especially with the ongoing Covid vaccination campaign and the looming spectre of flu season and potential Covid boosters.

The referral process will depend on local services, but in my experience these often involve convoluted bureaucratic forms. Automation can be achieved with IT protocols and GPs will need to push back and demand simpler, less labour intensive pathways.

As touched on above, obesity registers are likely to be under-populated and many patients will be missing from our clinical systems because we haven’t weighed them recently. Practices can tap into patient health data via digital platforms such as the NHS app and online services – but self-submitted weight may not be that accurate. Nevertheless, the direction of travel is to focus more on this area, and there is a requirement to identify as many new patients as possible and bring registers up to pre-pandemic levels as a minimum.

It is worth noting also that obesity rates tend to go hand in hand with both deprivation and workforce challenges. The areas of greatest need will face the greatest challenges, and to my eyes the ES specification does not address these.

Finally, the critical issue may not be what practices do, but what other services can provide in terms of capacity. Are they really going to be ready for workload tsunami coming their way? And is it going to make a difference? That is perhaps the biggest question mark here.

Is it worth signing up?

The ES is quite complicated and my initial impression is that it seems somewhat bureaucratic, with the referral allocations being subject to change.

The BMA GP Committee has been very critical of the ES, calling it ‘fundamentally flawed’. Certainly, I don’t think this is the grand solution that the obesity crisis deserves and the funding won’t make a huge difference to the average practice either. It feels more like an afterthought or a gesture.

In spite of the above reservations, however, I think for most practices it will be worth signing up and that they will be able to make it work in a pragmatic way.

I imagine virtually all practices refer patients to weight management services already, where there are sufficient services in their area. By undertaking some rudimentary searches and making the associated claims, there is additional funding to be obtained here without a large amount of extra or new work.

A significant proportion of obese patients also have chronic diseases, such as diabetes, hypertension and coronary heart disease, and as such attend regular reviews already. Don’t forget that weight/BMI measurement is a core component of these reviews already. Why would you take a measurement without discussing the result? Given the health risks of obesity, we absolutely should be discussing its implications (sensitively, and mindful of the limitations of BMI as a measurement).

If referral pathways are smooth and sensible – and IT protocols can be quickly implemented to support this – the ES should not generate a major amount of extra work for this cohort.

Assessing patients who don’t have a chronic disease will generate extra work, and the cost effectiveness of this should be considered separately, being mindful of how close the practice is to its referral allocation.

In summary:

• Practices have until 31 July 2021 to sign up for the ES
• There is a twin focus on: developing the supportive environment/refining the obesity register; and assessing/referring patients
• Payment is not for activity, but for accepted referrals. As such, practices who work hard and invest time in training and development could be poorly remunerated if local services are limited or unpopular with patients
• The ES is likely to be worth up to £3,000 for a practice of 10,000 patients – but achievement will vary and may not necessarily correspond to the hours invested
• There is scope to secure some funding purely by referring opportunistically from chronic disease reviews – but extra time will be required to sensitively discuss obesity and complete the referrals.

Dr David Coleman is a GP partner and PCN Co-Clinical Director in South Yorkshire