Occupational Medicine 2015;65:78–85 doi:10.1093/occmed/kqu176
Implementing NICE obesity guidance for staff: an NHS trust audit M. B. Dalton Department of Occupational Health, University Hospitals of Morecambe Bay NHS Foundation Trust, Furness General Hospital, Dalton Lane, Barrow in Furness, Cumbria LA14 4LF, UK. Correspondence to: M. B. Dalton, 1 Aldercroft, Kendal, Cumbria LA9 5BQ, UK. Tel: +44 (0)1539 241693; e-mail: [email protected]
Aims
To record in an NHS trust baseline assessment and management of obesity by its occupational health (OH) service staff, with reference to the standards in CG43, enabling deficiencies to be identified and improvements to be recommended as a benchmark for future measurement.
Methods
Criteria relevant to OH in CG43 were identified and data were collected from trust policies, interviews with managers, questionnaires to OH staff, examination of OH resources and case notes of staff attending OH. Results were checked for compliance with CG43 standards.
Results
Although the trust met NICE standards as an employer, significant lack of compliance was found in its OH service. Only 53% of staff attending medical examinations had weight recorded, OH resources were inadequate and 75% of its staff had received no training. Problems identified included lack of written guidance, time and care pathways. The resulting action plan included a consultant-led working party liaising with the trust’s health and well-being committee, training, enhanced OH resources, an obesity protocol, a database and weight management clinics.
Conclusions We found not only a lack of OH policy guidance but apparent inertia in dealing with obesity. The action plan demonstrated how OH clinical practice can draw upon CG43 to combat obesity in an NHS workforce. Key words
Audit; guidelines; NHS occupational health department; NICE; obesity.
Introduction In its 2006 guidance on the prevention, identification, assessment and management of obesity (CG43), the UK National Institute for Health and Clinical Excellence (NICE) prepared the first specific UK guidance on workplace interventions for obesity [1]. NICE guidance is non-binding advice intended to assist the National Health Service (NHS) in the exercise of its statutory duties. NHS bodies are entitled to take decisions that do not follow such guidance if they have good reason to do so [2]. In England, the Department of Health expects NICE guidance to be implemented consistently throughout the NHS in compliance with core standard C5 and developmental standard D2 and D13 of ‘Standards for Better Health’ [3]. Compliance
is a requirement of the NHS Litigation Authority [4] and guidelines are likely to emerge as a body of ‘reasonable’ opinion for the purposes of litigation [5]. The Department of Health recommended five ‘High Impact Changes’ for NHS organizations in 2014, including embedding NICE public health guidance and providing health promotion from accredited occupational health (OH) services [6]. The Health and Social Care Act (Part 8) charged the Care Quality Commission (CQC) with determining NHS trusts’ compliance with NICE guidance in England [7]. The focus of the World Health Organization (WHO) [8] on obesity as a serious medical condition, listed in the International Classification of Diseases as E66, and Foresight’s prediction of rising UK prevalence from 36% of men and 28% of women currently to 60% and 50%,
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Background The UK National Institute of Health and Clinical Excellence (NICE) has produced guidelines (CG43) on preventing and managing overweight and obesity, which apply to the National Health Service (NHS) as an employer.
M. B. DALTON: NICE OBESITY GUIDANCE FOR NHS STAFF 79
Methods We undertook the audit in an acute hospital NHS trust on four sites in Northwest England. The trust employed 10 000 staff, served 800 000 people and
recorded 18.4 days/year average sickness days/employee, compared with the NHS national average of 10.7. Socioeconomic deprivation, with which obesity positively correlates, dominated its employment catchment area, with life expectancy 4 years less than national average. The North–West Strategic Health Authority had the largest number of admissions with an obesity diagnosis and the most obesity-related prescriptions in the UK in 2008. The audit’s intention was to measure the extent and quality of trust and OH compliance with CG43. Its remit included the staff of the trust and its OH department. The Northwest Ethics Committee, Trust Governance Department and OH manager approved the audit, which was registered with the Trust Audit Department. As a working document for OH departments, CG43 has some shortcomings, being a complex work of 2351 pages. At its heart was the establishment of key standards covering policy, record-keeping and clinical practice. CG43 was summarized to identify areas of relevance to OH and nine criteria derived from it formed the basis for the audit (Table 1). A protocol was also designed, compliant with Faculty of Occupational Medicine guidance [14], for audit of process including the knowledge and attitudes of staff. A study day for OH clinical staff introduced the audit. Bespoke questionnaires were distributed. Collecting tools for each criterion were devised. The audit standard was 100% compliance. Measures established ensured the data collected were anonymized. To address criterion 1 (trust-wide policies to manage staff obesity), qualitative data were collected from trust policies and minutes, a NICE database, and interviews with managers of facilities, catering, transport, dietetics, exercise, human resources, manual handling and health improvement. Interviews were based on a system used in a national evaluation [15]. To address criterion 2 (programmes to manage obesity), the OH manager was interviewed. To address criterion 3 (training needs, knowledge, attitudes and barriers to obesity management in clinical OH staff), paper questionnaires using CG43 information were designed by the author, assisted by the trust’s audit department and completed by 11 doctors and 20 nurses. To address criterion 4 (the adequacy of specialist settings for treating obese staff), six OH clinical rooms on the main trust site were examined for equipment and information. To address criterion 5 (use of opportunities like routine health checks to measure weight, height, waist size and body mass index [BMI] and to advise on risk), data were manually retrieved from a random sample, suggested by the trust’s audit advisor, of 300 pre-employment OH clinical notes in June 2010, examined to confirm what data were being routinely collected. Although CG43 does not recommend waist circumference measurement routinely, it
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respectively, by 2050, underpin NICE obesity guidance [9]. The technological revolution of the 20th century has left in its wake an ‘obesogenic’ environment [9]. The rising prevalence of obesity suggests that factors in the work environment, such as use of technology, opportunities for physical activity, use of motor transport, food price, access to food and work/home lifestyle patterns, affect both energy intake and expenditure. In a longterm strategy to tackle obesity, the role of employers may be a dominant influence [9]. In 2010, the Health and Work Development Unit (HWDU) performed a national audit in NHS trusts of the six NICE guidelines relevant to workplace health [10]. CG43, the only clinical guideline in the portfolio of public health documents, was regarded the hardest to implement and identified as one on which little work was being done. Establishing a link between staff health and well-being and patient outcomes was considered a key factor in trust’s compliance with NICE guidances. Subsequent to CG43, the Department of Health commissioned a review led by Dr Steven Boorman into the health and well-being of NHS staff [11]. This looked particularly at sickness absence in the NHS and found it cost £1.7 billion annually. It advocated high-quality prevention and early intervention for illnesses common in NHS staff, with the aim of reducing sickness absence by one-third. Tackling obesity was considered a key priority. A number of initiatives additional to the recommendations of CG43 were suggested and the role of OH in these was highlighted. The review concluded that organizations that prioritized staff health and well-being performed better, with improved patient satisfaction, stronger quality scores and better outcomes, than those that did not. Sir Bruce Keogh’s review reinforced this message, making it clear that staff health and well-being were key to a quality improvement strategy [12]. A survey of all UK NHS trusts by the Chartered Society of Physiotherapists found that fewer than two-thirds of trusts had a health and well-being strategy, but that those with such strategies experienced lower sick pay costs [13]. It could, therefore, be argued that improving staff health and wellbeing by reducing obesity is likely to improve patient outcomes and have financial benefits. NICE considered that the NHS should set an example as an employer in developing policies to prevent and manage obesity and that its OH services should have an important role in this [1]. In view of this, we conducted an audit to determine whether the guidance was being implemented.
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Table 1. Audit results Compliance with criteria
Criterion 1: All workplaces should address prevention and management of obesity
NICE guidelines database with electronic tracker of compliance, needs assessment, CG43 implementation group, staff survey, Health and Work Group, obesity strategy. Improvements in catering, stairwells and exercise facilities, staff recreational and education programmes, active travel policies, health checks OH manager only present in Health and Work Group (disbanded 2008) with no change to OH clinical practice, no OH obesity policy/ protocol or links to weight management services • 15 of 20 (75%) OH clinicians declared they had received no training in obesity management • 13 of 20 (65%) OH clinicians were unaware of NICE Obesity Guidelines In six clinical rooms examined: • Adequately sized bed: 2 • Adequately sized chair: 1 • Sphygmomanometer with large cuff: 1 • Calibrated weighing scale: 3 • Height measure: 0 • Tape (waist) measure: 0 • BMI conversion chart: 1 No information about obesity management in clinical or waiting rooms • 160 (65%) of 300 workers attending OH medical examinations had weight recorded. No waist circumferences were recorded
Criterion 2: OH should support the implementation of workplace programmes to prevent and manage obesity Criterion 3: Healthcare professionals delivering interventions should have undergone training on best practice approach to prevention, treatments (including use of motivation techniques), barriers and be confident. Criterion 4: Specialist settings for treating obese people should be equipped with adequate seating, weighing and monitoring equipment
Criterion 5: Health professionals should use clinical judgement to decide when to measure a person’s weight. Opportunities include consultations for obesity-related medical conditions and routine health checks • Obesity should be classified and patients informed. • • • BMI should be used as the measure of overweight and waist circumference used additionally where BMI < 35 • Patients should be informed of long-term risk using the • NICE Matrix • • Criterion 6: Enquiry should be made into underlying causes of weight gain (diet, exercise, psychological distress, socioeconomic difficulties, previous failure to lose weight, motivation, obesogenic medication) • Criterion 7: Healthcare practitioners should use clinical judgement to investigate comorbidities (hypertension, type 2 diabetes, cardiovascular disease, osteoarthritis, sleep apnoea) • Criterion 8. Healthcare practitioners should consult the NICE Matrix to decide on intervention for the overweight patient Criterion 9: Multi-interventions should be offered using the • NICE Matrix as a guide: • Diets providing 600 kcal/day deficit for sustainable weight loss • 40–60 min of moderate activity/day to prevent obesity • Behavioural interventions delivered with the support of a trained professional • Drug treatment for patients who have not reached their target weight or have reached a plateau with dietary, physical activity and behavioural modifications alone • Bariatric surgery if BMI > 40 or 35–40 with other significant disease that could be improved by weight loss.
is advised as an indicator of risk of long-term health problems. To address the risk from obesity, in criteria 6 (causes of obesity) and 7 (comorbidities) the sample size was increased until 50 cases of raised
No classification of overweight/obesity was recorded No waist circumferences were recorded 23 (14%) of 160 workers had normal BMI; 37 (23%) had BMI > 30 21(42%) of obese workers sampled had been advised on risk Causes of obesity had been recorded in 31 (62%) of a sample of 50 obese workers omorbidities were recorded in 44 (88%) of a sample of 50 obese C workers here were no recordings of NICE Matrix use in the sample of 50 T obese workers 8 (56%) of a sample of 50 obese workers had been offered multiple 2 interventions for treatment
BMI had been identified to determine what information on causes of weight gain and comorbidities had been recorded. To address criteria 8 and 9 (offering interventions to patients using CG43’s assessment
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Criteria
M. B. DALTON: NICE OBESITY GUIDANCE FOR NHS STAFF 81
and management matrix), the 50 cases were examined to assess what interventions had been discussed and offered. Quantitative data were tabulated and presented as descriptive statistics without inference, expressed as raw numbers and percentages. To complete the audit an action plan, to follow analysis of the results, was planned. CG43’s ‘Guidance to Resources to Support Implementation’ [16] and Littlejohn’s and Cluzeau’s model [17] were used to devise the plan. The plan’s terms of reference were to define priorities, targets and timeframes, address staff motivation, stimulate change (championed by a figurehead), ensure ‘user-friendliness’ and the quality of written tools and to communicate the findings to key stakeholders.
Table 1 presents a summary of the audit criteria and principal findings. The trust’s compliance with criterion 1 is supported by a generic system for adoption of NICE guidance. CG43 was disseminated by the Chief Audit Coordinator to senior heads within the trust and the Drug and Therapeutics Committee. The Chief Audit Coordinator prepared baseline audit collecting tools, organized staff briefings, ensured maintenance of the NICE database on the trust intranet and informed the Governance Committee of progress. The Drug and Therapeutics Committee oversaw the implementation of CG43,
Table 2. OH clinical staff questionnaire on barriers and attitudes towards obesity (n = 20) Strongly agree, n (%) 1. I don’t consider obesity a disease 2. There is no culture within the trust that considers obesity worth addressing 3. Bringing up the subject of obesity risks alienating the patient 4. I lack the motivation to address issues of obesity 5. The outcomes of dealing with obese patients have been negative 6. I dislike the unpleasant aspects obesity sometimes presents 7. I have not the time nor inclination to open a ‘Pandora’s box’ of problems that often accompanies the obesity diagnosis 8. I am overweight myself, which makes it difficult for me to address the issue in patients 9. I don’t feel that I have the appropriate clinical competence to deal with the issue of obesity 10. I am concerned about inducing eating disorders such as anorexia 11. I do not consider obesity a priority in the time available
Agree, n (%)
Neither agree nor disagree, n (%)
Disagree, n (%)
Strongly disagree, n (%)
0 0
4 (20) 4 (20)
2 (10) 2 (10)
8 (40) 8 (40)
6 (30) 6 (30)
0
10 (50)
3 (15)
7 (35)
0
0
4 (20)
6 (30)
8 (40)
2 (10)
0
9 (45)
7 (35)
4 (20)
0
0
5 (25)
7 (35)
5 (25)
3 (15)
0
9 (45)
5 (25)
6 (30)
0
1(5)
3 (15)
3 (15)
12 (60)
1 (5)
1 (5)
2 (10)
6 (30)
10 (50)
1 (5)
0
2 (10)
3 (15)
11 (55)
4 (20)
10 (50)
1 (5)
6 (30)
1 (5)
2 (10)
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Results
allocating to the Division of Facilities the responsibility for developing the CG43 implementation group and an impact analysis. The CG43 implementation group (which included the OH manager) formulated an action plan including establishment of the Health and Work Group enabling the Obesity Strategy in 2007. The latter comprised a staff survey, nutrition steering group, educational programmes, improvements in catering, use of better-designed stairwells rather than lifts, recreational and exercise facilities offering basic health checks and promotion of walking and cycling on-site with shower provision. The CQC had granted the trust partial compliance with CG43 in recognition of the adoption of two policies affecting patients: maternity management and care of the bariatric patient. In addressing criterion 2, the audit found that in 2007, the trust was in the process of adopting policies to tackle better patient outcomes and staff sickness absence, and although an ‘Obesity Strategy’ for staff had been outlined by a Health and Work Group, OH had played a managerial role in the Obesity Strategy, which occasioned no change to OH clinical practice. There was no explicit policy targeting obesity in staff adopted by the OH department, OH had no obesity protocols and did not provide opportunities for overweight staff to seek advice about weight. For criterion 3, 20 responses out of 21 questionnaires were completed. Attitudes are summarized in Table 2. Three quarters of subjects said they had no training in
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Table 3. Seven-step obesity strategy for OH Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
obesity management and 65% were unaware of CG43. A significant majority of clinicians noted three other barriers to obesity management, namely lack of written guidance, lack of a care pathway and lack of time. The audit of equipment and resources (criterion 4) found that three of the six clinical rooms had weighing scales. None had height or tape measures and one had a BMI conversion chart. One large chair, one large sphygmomanometer cuff and two large beds were available in total. No information relating to obesity was available in clinical or waiting rooms. The audit of height, weight, waist and BMI details in staff records (criterion 5) showed just over half (160) had height and weight recorded, of which just >14% (23) had normal BMI, 86% (137) had BMI > 24.9 (overweight) and 23% (37) had BMI > 30 (obese). As no waist circumference measurements were recorded, identification of raised BMI due to increased muscle mass was not possible. On auditing the extended sample for compliance with criteria 6–9, it was found that, of those with BMI > 30, twothirds had been asked about causes and 42% with BMI > 30 had been advised about risks. Eighty-eight per cent had some comorbidity recorded. Just over half had been offered multiple interventions. There was no recorded use of NICE’s recommended matrix of appropriate interventions and risk.
Discussion This audit identified that even though there was some good management of overweight in OH there was no health and well-being objective and no obesity policy or coordinated protocols. The department was poorly resourced and BMI was not routinely recorded nor obesity comprehensively treated. Many clinicians were unaware of CG43 and this was compounded by absence of training and significant barriers to addressing the issues
the guidance raised. The overall impression was that despite the trust’s overall compliance with CG43, obesity was not considered a serious condition by OH. The trust had an established strategy for managing NICE guidance, including CG43, and some departments had begun implementation. As part of the trust’s action plan and as a member of a Health and Work Group, the OH business manager was aware of the guidance. The public health element of CG43 was prioritized, with generic improvements in catering, exercise facilities and health checks for staff, but CG43’s implications for clinical OH practice had not been acknowledged. The Health and Work Group disbanded in 2008 with the assumption its role was complete. Arguably missing the key opportunity for a senior OH clinician on the Health and Work Group to take the initiative with CG43 lead to the OH department’s inertia, underlining the importance of the conclusions of Boorman and other researchers on the need for managers to lead a culture of health and wellbeing in the workplace and to link objectives with OH [10,11,18]. To address the audit’s findings, an action plan outlining a departmental obesity strategy (Table 3) was devised and presented to the department’s consultant, the trust health and well-being committee, the HR director, the audit/clinical governance lead and to OH clinicians. It included an abridged version of CG43 (Table 4) as a user-friendly document to facilitate implementation. Research shows that two factors are essential to implement guidance successfully: clinical leadership of any action plan and close involvement of stakeholders [19]. The action plan recommended both. The aim of the audit was simple to discover whether the trust was complying with CG43. It was aided by unrestricted access to trust documentation, helpful responses
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Step 7
Leadership of strategy by a senior OH consultant who networked with key stakeholders through membership of the health and well-being committee, ensuring maintenance of momentum and the multidisciplinary approach advised by NICE Working party including senior OH nurse, health improvement manager and specialist registrar to develop strategy Training for OH staff in understanding obesity and its prevention, assessment and management A standard operating procedure condensing CG43 into an A4 folded document for rapid obesity assessment/ management (Table 4) Department equipped with scales, height and tape measures, appropriate beds and chairs, BMI charts, NICE and other documents for patients Database established to include • Document control centre: patient documents, e.g. trust dieticians information, NICE documents and standard operating procedure • Commercial weight management programmes, e.g. Weight Watchers • British Heart Foundation Toolkit • Care pathways, e.g. health trainers, expert patient programme • Obesity research material Weight management clinics were established on one site for • Trust staff self-referral • Referral from OH clinics of moderate risk patients
M. B. DALTON: NICE OBESITY GUIDANCE FOR NHS STAFF 83
Table 4. Protocol for assessment and management of the overweight patient
• Diet • Exercise
Male waist size, cm m= 102
Obesity 1, 2 or 3 Increased risk High risk Very high risk High or very high risk Recommend referral to general practitioner for consideration of pharmacotherapy or bariatric surgery
• L ow-fat diet or 600 kcal/day-deficient diet in combination with expert support, e.g. OH Weight Management Clinic, Commercial Weight Management Group like ‘Weight Watchers’ • Exercise of 30 min/day of moderate intensity for 5 days/week to reduce risk of cardiovascular disease or type 2 diabetes • To prevent obesity, 40–60 min of moderately intense exercise per day • To avoid regaining lost weight, 60–90 min of moderately intense activity/day • The benefits of using a professional health trainer or expert patient programme • Counselling
from relevant departments and compliance from staff. As it involved a relatively large trust, with an overarching strategy for processing NICE guidance, this helped to give it credibility, although size was not a strong factor in determining whether or not CG43 was followed. Summarizing the weighty CG43 guidance to define clear-cut criteria relevant to OH was an important element of devising the audit. The audit’s weaknesses lie in its use of non-validated questionnaires and the fact that no repeat audit to complete the cycle was possible. Furthermore, budgetary provision, necessary
for the implementation of an action plan, was not part of the audit’s remit. Additionally, the nine NICE criteria audited could not be all subjected to objective evaluation, with issues of a qualitative nature requiring a more subjective assessment of compliance. Only one study, HWDU’s 2010 national audit of NHS trusts’ implementation of six NICE workplace guidelines, bore comparison to this study [10], but it did not research the thoroughness of implementation, indicating the need for further research. HWDU found
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1. Calculate the patient’s BMI Measure the patient’s weight in kilogram and enter the value here → Measure the patient’s height in centimetre and enter the value here→ Calculate BMI by dividing weight by height2 (kg/cm2) and enter the value here→ 2. Categorize weight Identify the patient’s weight category using the chart below and enter the Category here → BMI Weight category 18.5–24.9 Healthy (normal weight) 25.0–29.9 Overweight (raised waist) 30.0–34.9 Obesity 1 (raised waist) 35.0–39.9 Obesity 2 (raised waist) 40.0+ Obesity 3 (raised waist) 3. Categorize waist Determine the patient’s sex as f or m and measure their waist circumference in centimetre as f= x cm or m=x cm and enter the value here → Using the value f= or m= from above, calculate the patient’s waist category using the chart below and enter the Category here → Female waist size, cm Waist category f= 88 Very high (raised waist) 4. Assess the risk Using the weight and waist categories from categories 2 and 3, identify the patient’s ‘risk status’ using the chart below and enter the Status here → Overweight Low waist category No increased risk High waist category Increased risk Very high waist category High risk 5. Plan the care pathway No increased risk Increased risk Offer lifestyle advice about Offer lifestyle advice about
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in this audit and ‘anti-fat bias’, described in recent literature [30].
Key points
•• Obesity
is a chronic, relapsing, often disabling disease, relevant to employers and occupational health because of its relationship to absenteeism, presenteeism, early retirement, ergonomic problems, accidents, litigation, work stress and prejudice. UK National Institute of Health and Clinical Excellence recommends National Health Service trusts should implement its guidance to address obesity in their staff. •• This audit of an acute hospital trust found adequate trust compliance with UK National Institute of Health and Clinical Excellence obesity guidance but found that the occupational health service was failing to effect the prevention, identification and management of obesity identified in 23% of a sample of staff. •• The resulting action plan suggested policy initiatives on leadership, networking, training, staff and departmental resources, consistent clinical practices and pathways of care.
Acknowledgements I would like to thank my Educational Supervisor Dr Fiona Page for valuable guidance during the audit. Also gratefully acknow ledged are the Trust’s staff who contributed to the audit and Occupational Medicine for instruction regarding publication.
Conflicts of interest None declared.
References 1. National Institute for Health and Clinical Excellence. Obesity: Guidance on the Prevention, Identification, Assessment and Management of Overweight and Obesity in Adults and Children, December 2006. http://www.nice.org.uk/ guidance/cg43 (23 August 2014, date last accessed). 2. NHS Commissioning Board. Commissioning Policy: Implementation and Funding of Guidance Produced by the National Institute for Health and Clinical Excellence, April 2013. Reference: NHSCB/CP/05. www.england.nhs.uk/ wp-content/uploads/2013/04/cp-05.pdf (23 November 2014, date last accessed). 3. Department of Health. Standards for Better Health, 2004. webarchive.nationalarchives.gov.uk/20130107105354/ http:/...dh.gov.uk (23 August 2014, date last accessed). 4. NHS Litigation Authority. NHSLA Risk Management Standards 2013–14 for NHS Trusts providing Acute, Community, or Mental Health & Learning Disability Services and Non-NHS Providers of NHS Care (Version 1), March
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most NHS organizations had not taken action to manage obesity in their own workers. Only 15% of trusts had obesity policies, and the key barriers to compliance were sensitivity, staff not understanding benefits for themselves and their patients and lack of resources. Only 29% of trusts had conducted a formal needs assessment and consequently did not have a confident view on obesity levels. CG43 represents a new paradigm to manage obesity in the workplace. This audit and action plan, shared on the NICE Shared Learning Database, demonstrates how CG43 can be incorporated into OH practice and has several practical implications. Results suggest that there is an urgent need for a shift in thinking and for clear leadership and vision to enable successful implementation. Three elements of a comprehensive approach, encompassing both trust and OH practice, are suggested. Firstly, improved governance arrangements ensuring strong links between OH clinicians and trust NICE guidance committees, enhanced by OH systems for processing and auditing relevant guidance, thereafter included in doctors’ appraisals, should help compliance with guidance. Secondly, checking BMI opportunistically in OH, considered key to CG43’s compliance, is recommended by NICE [1], HWDU [10] and Boorman [11]. This may be considered contentious in patients presenting with conditions unrelated to weight gain, but it is acknowledged that patients who are reluctant to do so may prefer healthcare professionals to raise the issue [20]. NICE defers to professional judgement and recommends using routine health checks or referrals for obesity-related disorders to assess overweight/obesity [1]. It is clear that CG43 is specifically relevant to OH because obesity is a chronic, relapsing [8], often disabling disease [21] linked to early retirement [22], sickness absence [23], reduced productivity [24], litigation [25], work stress [26], injury [27], bias and stigmatization [28]. WHO [8], obesity experts [29] and NICE [1] suggest surmounting the barrier of sensitivity by treating obesity as a serious medical condition, paving the way for respectful dialogue. Improving the obesity-related aspects of professional education would also be valuable. Thirdly, given Boorman’s suggestion that trusts target staff health and well-being services according to need [11], this audit’s finding suggesting prevalence of overweight in 86% and obesity in 23% of the staff sampled supports the need for weight management services. Managing obesity in NHS staff could be improved by following HWDU’s guidance and by encouraging staff engagement [10] augmented by NICE tools for implementation of CG43 [16]. Finally, two areas where future qualitative evaluation of clinicians’ attitudes to obesity would be useful are those of barriers to the management of obesity identified
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from a national evaluation using time series analysis, audit of patients’ notes, and interviews. Br Med J 2004; 329:999. 16. National Institute for Health and Care Excellence. Nice Guidelines (CG 43.) December 2006 Tools and Resources. http://www.nice.org.uk/guidance/cg043/resources (23 November 2014, date last accessed). 17. Littlejohns P, Cluzeau F. Guidelines for evaluation. Fam Pract 2000;17:S3–S6. 18. Michie S, West MA. Measuring people and performance: an evidence-based framework applied to health service organisations. Int J Manag Rev 2004;5–6:91–111. 19. Spyridonidis D, Calnan M. Implementing clinical governance policy: NICE. Br J Health Care Man 2010;16:394–401. 20. House of Commons Health Committee. Third Report of Session 2003–04. Obesity. Vol. 1. London, UK: The Stationery Office Ltd, 2004. 21. Visscher TL, Rissanen A, Seidell JC et al. Obesity and unhealthy life-years in adult Finns: an empirical approach. Arch Intern Med 2004;164:1413–1420. 22. Narbro K, Jonsson E, Larsson B, Waaler H, Wedel H, Sjöström L. Economic consequences of sick-leave and early retirement in obese Swedish women. Int J Obes Relat Metab Disord 1996;20:895–903. 23. Neovius K, Johansson K, Kark M, Neovius M. Obesity status and sick leave: a systematic review. Obes Rev 2009;10:17–27. 24. Gates DM, Succop P, Brehm BJ, Gillespie GL, Sommers BD. Obesity and presenteeism: the impact of body mass index on workplace productivity. J Occup Environ Med 2008;50:39–45. 25. Ostbye T, Dement JM, Krause KM. Obesity and workers’ compensation: results from the Duke Health and Safety Surveillance System. Arch Intern Med 2007;167:766–773. 26. Ostry AS, Radi S, Louie AM, LaMontagne AD. Psychosocial and other working conditions in relation to body mass index in a representative sample of Australian workers. BMC Public Health 2006;6:53. 27. Jahnke SA, Poston WS, Haddock CK, Jitnarin N. Obesity and incident injury among career firefighters in the central United States. Obesity (Silver Spring) 2013;21:1505–1508. 28. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring) 2009;17:941–964. 29. Kushner RF. Clinical assessment and management of adult obesity. Circulation 2012;126:2870–2877. 30. Sabin JA, Marini M, Nosek BA. Implicit and explicit antifat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. Plos One 2012;9:1–7.
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2013. http://www.nhsla.com/safety/Documents/NHS%20 LA%20Risk%20Management%20Standards%20201314.pdf (23 November 2014, date last accessed). 5. Samanta A, Samanta J, Gunn M. Legal considerations of clinical guidelines: will NICE make a difference? J R Soc Med 2003;96:133–138. 6. Department of Health. Health and Well-Being Five High Impact Changes. www.nhsemployers.org (23 August 2014, date last accessed). 7. Care Quality Commission. Guidance About Compliance: Essential Standards of Quality and Safety. What Providers Should do to Comply with the Section 20 Regulations of the Health and Social Care Act 2008. www.cqc.org.uk (23 August 2014, date last accessed). 8. World Health Organisation. Obesity: Preventing and Managing the Global Epidemic: Consultation on Obesity. WHO/NUT/NCD/98.1. Technical Report Series Number 814. Geneva, Switzerland, 1997. http://www.who.int/ nutrition/publications/obesity_executive_summary.pdf (23 August 2014, date last accessed). 9. Government Office for Science and Department of Health. Foresight.Tackling Obesity—Future Choices (2nd edn). Project Report. 2007. https://www.gov.uk/government/publications/reducing-obesity-future-choices (23 August 2014, date last accessed). 10. Royal College of Physicians, Faculty of Occupational Medicine, Health and Work Development Unit. Implementating NICE Public Health Guidance for the Workplace. Overcoming Barriers and Sharing Success, 2012. https://www.rcplondon.ac.uk/sites/default/files/documents/ shipreport.pdf (23 November 2014, date last accessed). 11. NHS. Health and Well-Being Review. Interim Report. Department of Health, 2009. www.nhshealthandwellbeing.org/InterimReport.html (23 August 2014, date last accessed). 12. Keogh KBE. Review into the Quality of Care and Treatment Provided by 40 Trusts in England: An Overview Report, 2013. http://www.nhs.uk/nhsengland/bruce-keogh-review/documents/outcomes/keogh-review-final-report.pdf (23 August 2014, date last accessed). 13. Chartered Society of Physiotherapists. Fit Enough for Patients? An Audit of Workplace Health and Well-Being Services for NHS Staff, 2013. http://www.csp.org.uk/publications/fitenough-patients (23 November 2014, date last accessed). 14. Faculty of Occupational Medicine. Quality and Audit in Occupational Health, 1995. http://www.fom.ac.uk/ publications-policy-guidance-and-consultations 15. Sheldon TA, Cullum N, Dawson D et al. What’s the evidence that NICE guidance has been implemented? Results
Implementing NICE obesity guidance for staff: an NHS trust audit M. B. Dalton Department of Occupational Health, University Hospitals of Morecambe Bay NHS Foundation Trust, Furness General Hospital, Dalton Lane, Barrow in Furness, Cumbria LA14 4LF, UK. Correspondence to: M. B. Dalton, 1 Aldercroft, Kendal, Cumbria LA9 5BQ, UK. Tel: +44 (0)1539 241693; e-mail: [email protected]
Aims
To record in an NHS trust baseline assessment and management of obesity by its occupational health (OH) service staff, with reference to the standards in CG43, enabling deficiencies to be identified and improvements to be recommended as a benchmark for future measurement.
Methods
Criteria relevant to OH in CG43 were identified and data were collected from trust policies, interviews with managers, questionnaires to OH staff, examination of OH resources and case notes of staff attending OH. Results were checked for compliance with CG43 standards.
Results
Although the trust met NICE standards as an employer, significant lack of compliance was found in its OH service. Only 53% of staff attending medical examinations had weight recorded, OH resources were inadequate and 75% of its staff had received no training. Problems identified included lack of written guidance, time and care pathways. The resulting action plan included a consultant-led working party liaising with the trust’s health and well-being committee, training, enhanced OH resources, an obesity protocol, a database and weight management clinics.
Conclusions We found not only a lack of OH policy guidance but apparent inertia in dealing with obesity. The action plan demonstrated how OH clinical practice can draw upon CG43 to combat obesity in an NHS workforce. Key words
Audit; guidelines; NHS occupational health department; NICE; obesity.
Introduction In its 2006 guidance on the prevention, identification, assessment and management of obesity (CG43), the UK National Institute for Health and Clinical Excellence (NICE) prepared the first specific UK guidance on workplace interventions for obesity [1]. NICE guidance is non-binding advice intended to assist the National Health Service (NHS) in the exercise of its statutory duties. NHS bodies are entitled to take decisions that do not follow such guidance if they have good reason to do so [2]. In England, the Department of Health expects NICE guidance to be implemented consistently throughout the NHS in compliance with core standard C5 and developmental standard D2 and D13 of ‘Standards for Better Health’ [3]. Compliance
is a requirement of the NHS Litigation Authority [4] and guidelines are likely to emerge as a body of ‘reasonable’ opinion for the purposes of litigation [5]. The Department of Health recommended five ‘High Impact Changes’ for NHS organizations in 2014, including embedding NICE public health guidance and providing health promotion from accredited occupational health (OH) services [6]. The Health and Social Care Act (Part 8) charged the Care Quality Commission (CQC) with determining NHS trusts’ compliance with NICE guidance in England [7]. The focus of the World Health Organization (WHO) [8] on obesity as a serious medical condition, listed in the International Classification of Diseases as E66, and Foresight’s prediction of rising UK prevalence from 36% of men and 28% of women currently to 60% and 50%,
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Background The UK National Institute of Health and Clinical Excellence (NICE) has produced guidelines (CG43) on preventing and managing overweight and obesity, which apply to the National Health Service (NHS) as an employer.
M. B. DALTON: NICE OBESITY GUIDANCE FOR NHS STAFF 79
Methods We undertook the audit in an acute hospital NHS trust on four sites in Northwest England. The trust employed 10 000 staff, served 800 000 people and
recorded 18.4 days/year average sickness days/employee, compared with the NHS national average of 10.7. Socioeconomic deprivation, with which obesity positively correlates, dominated its employment catchment area, with life expectancy 4 years less than national average. The North–West Strategic Health Authority had the largest number of admissions with an obesity diagnosis and the most obesity-related prescriptions in the UK in 2008. The audit’s intention was to measure the extent and quality of trust and OH compliance with CG43. Its remit included the staff of the trust and its OH department. The Northwest Ethics Committee, Trust Governance Department and OH manager approved the audit, which was registered with the Trust Audit Department. As a working document for OH departments, CG43 has some shortcomings, being a complex work of 2351 pages. At its heart was the establishment of key standards covering policy, record-keeping and clinical practice. CG43 was summarized to identify areas of relevance to OH and nine criteria derived from it formed the basis for the audit (Table 1). A protocol was also designed, compliant with Faculty of Occupational Medicine guidance [14], for audit of process including the knowledge and attitudes of staff. A study day for OH clinical staff introduced the audit. Bespoke questionnaires were distributed. Collecting tools for each criterion were devised. The audit standard was 100% compliance. Measures established ensured the data collected were anonymized. To address criterion 1 (trust-wide policies to manage staff obesity), qualitative data were collected from trust policies and minutes, a NICE database, and interviews with managers of facilities, catering, transport, dietetics, exercise, human resources, manual handling and health improvement. Interviews were based on a system used in a national evaluation [15]. To address criterion 2 (programmes to manage obesity), the OH manager was interviewed. To address criterion 3 (training needs, knowledge, attitudes and barriers to obesity management in clinical OH staff), paper questionnaires using CG43 information were designed by the author, assisted by the trust’s audit department and completed by 11 doctors and 20 nurses. To address criterion 4 (the adequacy of specialist settings for treating obese staff), six OH clinical rooms on the main trust site were examined for equipment and information. To address criterion 5 (use of opportunities like routine health checks to measure weight, height, waist size and body mass index [BMI] and to advise on risk), data were manually retrieved from a random sample, suggested by the trust’s audit advisor, of 300 pre-employment OH clinical notes in June 2010, examined to confirm what data were being routinely collected. Although CG43 does not recommend waist circumference measurement routinely, it
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respectively, by 2050, underpin NICE obesity guidance [9]. The technological revolution of the 20th century has left in its wake an ‘obesogenic’ environment [9]. The rising prevalence of obesity suggests that factors in the work environment, such as use of technology, opportunities for physical activity, use of motor transport, food price, access to food and work/home lifestyle patterns, affect both energy intake and expenditure. In a longterm strategy to tackle obesity, the role of employers may be a dominant influence [9]. In 2010, the Health and Work Development Unit (HWDU) performed a national audit in NHS trusts of the six NICE guidelines relevant to workplace health [10]. CG43, the only clinical guideline in the portfolio of public health documents, was regarded the hardest to implement and identified as one on which little work was being done. Establishing a link between staff health and well-being and patient outcomes was considered a key factor in trust’s compliance with NICE guidances. Subsequent to CG43, the Department of Health commissioned a review led by Dr Steven Boorman into the health and well-being of NHS staff [11]. This looked particularly at sickness absence in the NHS and found it cost £1.7 billion annually. It advocated high-quality prevention and early intervention for illnesses common in NHS staff, with the aim of reducing sickness absence by one-third. Tackling obesity was considered a key priority. A number of initiatives additional to the recommendations of CG43 were suggested and the role of OH in these was highlighted. The review concluded that organizations that prioritized staff health and well-being performed better, with improved patient satisfaction, stronger quality scores and better outcomes, than those that did not. Sir Bruce Keogh’s review reinforced this message, making it clear that staff health and well-being were key to a quality improvement strategy [12]. A survey of all UK NHS trusts by the Chartered Society of Physiotherapists found that fewer than two-thirds of trusts had a health and well-being strategy, but that those with such strategies experienced lower sick pay costs [13]. It could, therefore, be argued that improving staff health and wellbeing by reducing obesity is likely to improve patient outcomes and have financial benefits. NICE considered that the NHS should set an example as an employer in developing policies to prevent and manage obesity and that its OH services should have an important role in this [1]. In view of this, we conducted an audit to determine whether the guidance was being implemented.
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Table 1. Audit results Compliance with criteria
Criterion 1: All workplaces should address prevention and management of obesity
NICE guidelines database with electronic tracker of compliance, needs assessment, CG43 implementation group, staff survey, Health and Work Group, obesity strategy. Improvements in catering, stairwells and exercise facilities, staff recreational and education programmes, active travel policies, health checks OH manager only present in Health and Work Group (disbanded 2008) with no change to OH clinical practice, no OH obesity policy/ protocol or links to weight management services • 15 of 20 (75%) OH clinicians declared they had received no training in obesity management • 13 of 20 (65%) OH clinicians were unaware of NICE Obesity Guidelines In six clinical rooms examined: • Adequately sized bed: 2 • Adequately sized chair: 1 • Sphygmomanometer with large cuff: 1 • Calibrated weighing scale: 3 • Height measure: 0 • Tape (waist) measure: 0 • BMI conversion chart: 1 No information about obesity management in clinical or waiting rooms • 160 (65%) of 300 workers attending OH medical examinations had weight recorded. No waist circumferences were recorded
Criterion 2: OH should support the implementation of workplace programmes to prevent and manage obesity Criterion 3: Healthcare professionals delivering interventions should have undergone training on best practice approach to prevention, treatments (including use of motivation techniques), barriers and be confident. Criterion 4: Specialist settings for treating obese people should be equipped with adequate seating, weighing and monitoring equipment
Criterion 5: Health professionals should use clinical judgement to decide when to measure a person’s weight. Opportunities include consultations for obesity-related medical conditions and routine health checks • Obesity should be classified and patients informed. • • • BMI should be used as the measure of overweight and waist circumference used additionally where BMI < 35 • Patients should be informed of long-term risk using the • NICE Matrix • • Criterion 6: Enquiry should be made into underlying causes of weight gain (diet, exercise, psychological distress, socioeconomic difficulties, previous failure to lose weight, motivation, obesogenic medication) • Criterion 7: Healthcare practitioners should use clinical judgement to investigate comorbidities (hypertension, type 2 diabetes, cardiovascular disease, osteoarthritis, sleep apnoea) • Criterion 8. Healthcare practitioners should consult the NICE Matrix to decide on intervention for the overweight patient Criterion 9: Multi-interventions should be offered using the • NICE Matrix as a guide: • Diets providing 600 kcal/day deficit for sustainable weight loss • 40–60 min of moderate activity/day to prevent obesity • Behavioural interventions delivered with the support of a trained professional • Drug treatment for patients who have not reached their target weight or have reached a plateau with dietary, physical activity and behavioural modifications alone • Bariatric surgery if BMI > 40 or 35–40 with other significant disease that could be improved by weight loss.
is advised as an indicator of risk of long-term health problems. To address the risk from obesity, in criteria 6 (causes of obesity) and 7 (comorbidities) the sample size was increased until 50 cases of raised
No classification of overweight/obesity was recorded No waist circumferences were recorded 23 (14%) of 160 workers had normal BMI; 37 (23%) had BMI > 30 21(42%) of obese workers sampled had been advised on risk Causes of obesity had been recorded in 31 (62%) of a sample of 50 obese workers omorbidities were recorded in 44 (88%) of a sample of 50 obese C workers here were no recordings of NICE Matrix use in the sample of 50 T obese workers 8 (56%) of a sample of 50 obese workers had been offered multiple 2 interventions for treatment
BMI had been identified to determine what information on causes of weight gain and comorbidities had been recorded. To address criteria 8 and 9 (offering interventions to patients using CG43’s assessment
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Criteria
M. B. DALTON: NICE OBESITY GUIDANCE FOR NHS STAFF 81
and management matrix), the 50 cases were examined to assess what interventions had been discussed and offered. Quantitative data were tabulated and presented as descriptive statistics without inference, expressed as raw numbers and percentages. To complete the audit an action plan, to follow analysis of the results, was planned. CG43’s ‘Guidance to Resources to Support Implementation’ [16] and Littlejohn’s and Cluzeau’s model [17] were used to devise the plan. The plan’s terms of reference were to define priorities, targets and timeframes, address staff motivation, stimulate change (championed by a figurehead), ensure ‘user-friendliness’ and the quality of written tools and to communicate the findings to key stakeholders.
Table 1 presents a summary of the audit criteria and principal findings. The trust’s compliance with criterion 1 is supported by a generic system for adoption of NICE guidance. CG43 was disseminated by the Chief Audit Coordinator to senior heads within the trust and the Drug and Therapeutics Committee. The Chief Audit Coordinator prepared baseline audit collecting tools, organized staff briefings, ensured maintenance of the NICE database on the trust intranet and informed the Governance Committee of progress. The Drug and Therapeutics Committee oversaw the implementation of CG43,
Table 2. OH clinical staff questionnaire on barriers and attitudes towards obesity (n = 20) Strongly agree, n (%) 1. I don’t consider obesity a disease 2. There is no culture within the trust that considers obesity worth addressing 3. Bringing up the subject of obesity risks alienating the patient 4. I lack the motivation to address issues of obesity 5. The outcomes of dealing with obese patients have been negative 6. I dislike the unpleasant aspects obesity sometimes presents 7. I have not the time nor inclination to open a ‘Pandora’s box’ of problems that often accompanies the obesity diagnosis 8. I am overweight myself, which makes it difficult for me to address the issue in patients 9. I don’t feel that I have the appropriate clinical competence to deal with the issue of obesity 10. I am concerned about inducing eating disorders such as anorexia 11. I do not consider obesity a priority in the time available
Agree, n (%)
Neither agree nor disagree, n (%)
Disagree, n (%)
Strongly disagree, n (%)
0 0
4 (20) 4 (20)
2 (10) 2 (10)
8 (40) 8 (40)
6 (30) 6 (30)
0
10 (50)
3 (15)
7 (35)
0
0
4 (20)
6 (30)
8 (40)
2 (10)
0
9 (45)
7 (35)
4 (20)
0
0
5 (25)
7 (35)
5 (25)
3 (15)
0
9 (45)
5 (25)
6 (30)
0
1(5)
3 (15)
3 (15)
12 (60)
1 (5)
1 (5)
2 (10)
6 (30)
10 (50)
1 (5)
0
2 (10)
3 (15)
11 (55)
4 (20)
10 (50)
1 (5)
6 (30)
1 (5)
2 (10)
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Results
allocating to the Division of Facilities the responsibility for developing the CG43 implementation group and an impact analysis. The CG43 implementation group (which included the OH manager) formulated an action plan including establishment of the Health and Work Group enabling the Obesity Strategy in 2007. The latter comprised a staff survey, nutrition steering group, educational programmes, improvements in catering, use of better-designed stairwells rather than lifts, recreational and exercise facilities offering basic health checks and promotion of walking and cycling on-site with shower provision. The CQC had granted the trust partial compliance with CG43 in recognition of the adoption of two policies affecting patients: maternity management and care of the bariatric patient. In addressing criterion 2, the audit found that in 2007, the trust was in the process of adopting policies to tackle better patient outcomes and staff sickness absence, and although an ‘Obesity Strategy’ for staff had been outlined by a Health and Work Group, OH had played a managerial role in the Obesity Strategy, which occasioned no change to OH clinical practice. There was no explicit policy targeting obesity in staff adopted by the OH department, OH had no obesity protocols and did not provide opportunities for overweight staff to seek advice about weight. For criterion 3, 20 responses out of 21 questionnaires were completed. Attitudes are summarized in Table 2. Three quarters of subjects said they had no training in
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Table 3. Seven-step obesity strategy for OH Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
obesity management and 65% were unaware of CG43. A significant majority of clinicians noted three other barriers to obesity management, namely lack of written guidance, lack of a care pathway and lack of time. The audit of equipment and resources (criterion 4) found that three of the six clinical rooms had weighing scales. None had height or tape measures and one had a BMI conversion chart. One large chair, one large sphygmomanometer cuff and two large beds were available in total. No information relating to obesity was available in clinical or waiting rooms. The audit of height, weight, waist and BMI details in staff records (criterion 5) showed just over half (160) had height and weight recorded, of which just >14% (23) had normal BMI, 86% (137) had BMI > 24.9 (overweight) and 23% (37) had BMI > 30 (obese). As no waist circumference measurements were recorded, identification of raised BMI due to increased muscle mass was not possible. On auditing the extended sample for compliance with criteria 6–9, it was found that, of those with BMI > 30, twothirds had been asked about causes and 42% with BMI > 30 had been advised about risks. Eighty-eight per cent had some comorbidity recorded. Just over half had been offered multiple interventions. There was no recorded use of NICE’s recommended matrix of appropriate interventions and risk.
Discussion This audit identified that even though there was some good management of overweight in OH there was no health and well-being objective and no obesity policy or coordinated protocols. The department was poorly resourced and BMI was not routinely recorded nor obesity comprehensively treated. Many clinicians were unaware of CG43 and this was compounded by absence of training and significant barriers to addressing the issues
the guidance raised. The overall impression was that despite the trust’s overall compliance with CG43, obesity was not considered a serious condition by OH. The trust had an established strategy for managing NICE guidance, including CG43, and some departments had begun implementation. As part of the trust’s action plan and as a member of a Health and Work Group, the OH business manager was aware of the guidance. The public health element of CG43 was prioritized, with generic improvements in catering, exercise facilities and health checks for staff, but CG43’s implications for clinical OH practice had not been acknowledged. The Health and Work Group disbanded in 2008 with the assumption its role was complete. Arguably missing the key opportunity for a senior OH clinician on the Health and Work Group to take the initiative with CG43 lead to the OH department’s inertia, underlining the importance of the conclusions of Boorman and other researchers on the need for managers to lead a culture of health and wellbeing in the workplace and to link objectives with OH [10,11,18]. To address the audit’s findings, an action plan outlining a departmental obesity strategy (Table 3) was devised and presented to the department’s consultant, the trust health and well-being committee, the HR director, the audit/clinical governance lead and to OH clinicians. It included an abridged version of CG43 (Table 4) as a user-friendly document to facilitate implementation. Research shows that two factors are essential to implement guidance successfully: clinical leadership of any action plan and close involvement of stakeholders [19]. The action plan recommended both. The aim of the audit was simple to discover whether the trust was complying with CG43. It was aided by unrestricted access to trust documentation, helpful responses
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Step 7
Leadership of strategy by a senior OH consultant who networked with key stakeholders through membership of the health and well-being committee, ensuring maintenance of momentum and the multidisciplinary approach advised by NICE Working party including senior OH nurse, health improvement manager and specialist registrar to develop strategy Training for OH staff in understanding obesity and its prevention, assessment and management A standard operating procedure condensing CG43 into an A4 folded document for rapid obesity assessment/ management (Table 4) Department equipped with scales, height and tape measures, appropriate beds and chairs, BMI charts, NICE and other documents for patients Database established to include • Document control centre: patient documents, e.g. trust dieticians information, NICE documents and standard operating procedure • Commercial weight management programmes, e.g. Weight Watchers • British Heart Foundation Toolkit • Care pathways, e.g. health trainers, expert patient programme • Obesity research material Weight management clinics were established on one site for • Trust staff self-referral • Referral from OH clinics of moderate risk patients
M. B. DALTON: NICE OBESITY GUIDANCE FOR NHS STAFF 83
Table 4. Protocol for assessment and management of the overweight patient
• Diet • Exercise
Male waist size, cm m= 102
Obesity 1, 2 or 3 Increased risk High risk Very high risk High or very high risk Recommend referral to general practitioner for consideration of pharmacotherapy or bariatric surgery
• L ow-fat diet or 600 kcal/day-deficient diet in combination with expert support, e.g. OH Weight Management Clinic, Commercial Weight Management Group like ‘Weight Watchers’ • Exercise of 30 min/day of moderate intensity for 5 days/week to reduce risk of cardiovascular disease or type 2 diabetes • To prevent obesity, 40–60 min of moderately intense exercise per day • To avoid regaining lost weight, 60–90 min of moderately intense activity/day • The benefits of using a professional health trainer or expert patient programme • Counselling
from relevant departments and compliance from staff. As it involved a relatively large trust, with an overarching strategy for processing NICE guidance, this helped to give it credibility, although size was not a strong factor in determining whether or not CG43 was followed. Summarizing the weighty CG43 guidance to define clear-cut criteria relevant to OH was an important element of devising the audit. The audit’s weaknesses lie in its use of non-validated questionnaires and the fact that no repeat audit to complete the cycle was possible. Furthermore, budgetary provision, necessary
for the implementation of an action plan, was not part of the audit’s remit. Additionally, the nine NICE criteria audited could not be all subjected to objective evaluation, with issues of a qualitative nature requiring a more subjective assessment of compliance. Only one study, HWDU’s 2010 national audit of NHS trusts’ implementation of six NICE workplace guidelines, bore comparison to this study [10], but it did not research the thoroughness of implementation, indicating the need for further research. HWDU found
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1. Calculate the patient’s BMI Measure the patient’s weight in kilogram and enter the value here → Measure the patient’s height in centimetre and enter the value here→ Calculate BMI by dividing weight by height2 (kg/cm2) and enter the value here→ 2. Categorize weight Identify the patient’s weight category using the chart below and enter the Category here → BMI Weight category 18.5–24.9 Healthy (normal weight) 25.0–29.9 Overweight (raised waist) 30.0–34.9 Obesity 1 (raised waist) 35.0–39.9 Obesity 2 (raised waist) 40.0+ Obesity 3 (raised waist) 3. Categorize waist Determine the patient’s sex as f or m and measure their waist circumference in centimetre as f= x cm or m=x cm and enter the value here → Using the value f= or m= from above, calculate the patient’s waist category using the chart below and enter the Category here → Female waist size, cm Waist category f= 88 Very high (raised waist) 4. Assess the risk Using the weight and waist categories from categories 2 and 3, identify the patient’s ‘risk status’ using the chart below and enter the Status here → Overweight Low waist category No increased risk High waist category Increased risk Very high waist category High risk 5. Plan the care pathway No increased risk Increased risk Offer lifestyle advice about Offer lifestyle advice about
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in this audit and ‘anti-fat bias’, described in recent literature [30].
Key points
•• Obesity
is a chronic, relapsing, often disabling disease, relevant to employers and occupational health because of its relationship to absenteeism, presenteeism, early retirement, ergonomic problems, accidents, litigation, work stress and prejudice. UK National Institute of Health and Clinical Excellence recommends National Health Service trusts should implement its guidance to address obesity in their staff. •• This audit of an acute hospital trust found adequate trust compliance with UK National Institute of Health and Clinical Excellence obesity guidance but found that the occupational health service was failing to effect the prevention, identification and management of obesity identified in 23% of a sample of staff. •• The resulting action plan suggested policy initiatives on leadership, networking, training, staff and departmental resources, consistent clinical practices and pathways of care.
Acknowledgements I would like to thank my Educational Supervisor Dr Fiona Page for valuable guidance during the audit. Also gratefully acknow ledged are the Trust’s staff who contributed to the audit and Occupational Medicine for instruction regarding publication.
Conflicts of interest None declared.
References 1. National Institute for Health and Clinical Excellence. Obesity: Guidance on the Prevention, Identification, Assessment and Management of Overweight and Obesity in Adults and Children, December 2006. http://www.nice.org.uk/ guidance/cg43 (23 August 2014, date last accessed). 2. NHS Commissioning Board. Commissioning Policy: Implementation and Funding of Guidance Produced by the National Institute for Health and Clinical Excellence, April 2013. Reference: NHSCB/CP/05. www.england.nhs.uk/ wp-content/uploads/2013/04/cp-05.pdf (23 November 2014, date last accessed). 3. Department of Health. Standards for Better Health, 2004. webarchive.nationalarchives.gov.uk/20130107105354/ http:/...dh.gov.uk (23 August 2014, date last accessed). 4. NHS Litigation Authority. NHSLA Risk Management Standards 2013–14 for NHS Trusts providing Acute, Community, or Mental Health & Learning Disability Services and Non-NHS Providers of NHS Care (Version 1), March
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most NHS organizations had not taken action to manage obesity in their own workers. Only 15% of trusts had obesity policies, and the key barriers to compliance were sensitivity, staff not understanding benefits for themselves and their patients and lack of resources. Only 29% of trusts had conducted a formal needs assessment and consequently did not have a confident view on obesity levels. CG43 represents a new paradigm to manage obesity in the workplace. This audit and action plan, shared on the NICE Shared Learning Database, demonstrates how CG43 can be incorporated into OH practice and has several practical implications. Results suggest that there is an urgent need for a shift in thinking and for clear leadership and vision to enable successful implementation. Three elements of a comprehensive approach, encompassing both trust and OH practice, are suggested. Firstly, improved governance arrangements ensuring strong links between OH clinicians and trust NICE guidance committees, enhanced by OH systems for processing and auditing relevant guidance, thereafter included in doctors’ appraisals, should help compliance with guidance. Secondly, checking BMI opportunistically in OH, considered key to CG43’s compliance, is recommended by NICE [1], HWDU [10] and Boorman [11]. This may be considered contentious in patients presenting with conditions unrelated to weight gain, but it is acknowledged that patients who are reluctant to do so may prefer healthcare professionals to raise the issue [20]. NICE defers to professional judgement and recommends using routine health checks or referrals for obesity-related disorders to assess overweight/obesity [1]. It is clear that CG43 is specifically relevant to OH because obesity is a chronic, relapsing [8], often disabling disease [21] linked to early retirement [22], sickness absence [23], reduced productivity [24], litigation [25], work stress [26], injury [27], bias and stigmatization [28]. WHO [8], obesity experts [29] and NICE [1] suggest surmounting the barrier of sensitivity by treating obesity as a serious medical condition, paving the way for respectful dialogue. Improving the obesity-related aspects of professional education would also be valuable. Thirdly, given Boorman’s suggestion that trusts target staff health and well-being services according to need [11], this audit’s finding suggesting prevalence of overweight in 86% and obesity in 23% of the staff sampled supports the need for weight management services. Managing obesity in NHS staff could be improved by following HWDU’s guidance and by encouraging staff engagement [10] augmented by NICE tools for implementation of CG43 [16]. Finally, two areas where future qualitative evaluation of clinicians’ attitudes to obesity would be useful are those of barriers to the management of obesity identified
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from a national evaluation using time series analysis, audit of patients’ notes, and interviews. Br Med J 2004; 329:999. 16. National Institute for Health and Care Excellence. Nice Guidelines (CG 43.) December 2006 Tools and Resources. http://www.nice.org.uk/guidance/cg043/resources (23 November 2014, date last accessed). 17. Littlejohns P, Cluzeau F. Guidelines for evaluation. Fam Pract 2000;17:S3–S6. 18. Michie S, West MA. Measuring people and performance: an evidence-based framework applied to health service organisations. Int J Manag Rev 2004;5–6:91–111. 19. Spyridonidis D, Calnan M. Implementing clinical governance policy: NICE. Br J Health Care Man 2010;16:394–401. 20. House of Commons Health Committee. Third Report of Session 2003–04. Obesity. Vol. 1. London, UK: The Stationery Office Ltd, 2004. 21. Visscher TL, Rissanen A, Seidell JC et al. Obesity and unhealthy life-years in adult Finns: an empirical approach. Arch Intern Med 2004;164:1413–1420. 22. Narbro K, Jonsson E, Larsson B, Waaler H, Wedel H, Sjöström L. Economic consequences of sick-leave and early retirement in obese Swedish women. Int J Obes Relat Metab Disord 1996;20:895–903. 23. Neovius K, Johansson K, Kark M, Neovius M. Obesity status and sick leave: a systematic review. Obes Rev 2009;10:17–27. 24. Gates DM, Succop P, Brehm BJ, Gillespie GL, Sommers BD. Obesity and presenteeism: the impact of body mass index on workplace productivity. J Occup Environ Med 2008;50:39–45. 25. Ostbye T, Dement JM, Krause KM. Obesity and workers’ compensation: results from the Duke Health and Safety Surveillance System. Arch Intern Med 2007;167:766–773. 26. Ostry AS, Radi S, Louie AM, LaMontagne AD. Psychosocial and other working conditions in relation to body mass index in a representative sample of Australian workers. BMC Public Health 2006;6:53. 27. Jahnke SA, Poston WS, Haddock CK, Jitnarin N. Obesity and incident injury among career firefighters in the central United States. Obesity (Silver Spring) 2013;21:1505–1508. 28. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring) 2009;17:941–964. 29. Kushner RF. Clinical assessment and management of adult obesity. Circulation 2012;126:2870–2877. 30. Sabin JA, Marini M, Nosek BA. Implicit and explicit antifat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. Plos One 2012;9:1–7.
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