Abstract
Background
The National Health Service in England is piloting an extension of access to its Digital Weight Management Programme, a digital service to support behavioural and lifestyle changes for weight loss. Access is being piloted to include referrals for patients with a body mass index above a threshold level set by the National Health Service England and who either have a diagnosis of osteoarthritis of the knee or hip (musculoskeletal referrals – 11 pilot sites) or are on elective surgical care waiting lists (elective care referrals – 10 pilot sites). There is a marked variation across sites in the number of patients referred.
Objectives
To understand reasons for variation (local implementation, barriers and facilitators) and experiences of the implementation and functioning of referral pathways for musculoskeletal and elective surgical care patients into the National Health Service Digital Weight Management Programme.
Design and methods
A comparative case study (
n
= 7 sites) methodology was used, employing a mixed-methods approach following a sequential explanatory design: descriptive analysis of quantitative referral data from National Health Service England; staff (
n
= 25) and patient (
n
= 18) interviews and online workshops. Thematic analysis was conducted.
Setting
Osteoarthritis treatment and elective surgery providers in the National Health Service in England.
Participants
Interviews: staff and patients at three musculoskeletal and four elective care pilot sites. Workshops: staff at all pilot sites.
Intervention
Referral of osteoarthritis and elective surgery patients to the National Health Service Digital Weight Management Programme.
Main outcome measures
Patients’ and staff’s views.
Results
Sites that created referral processes that optimised clinical staff time (e.g. automation and use of administrative staff) and involved ways to capture body mass index if missing from patient records were more likely to have a higher number of referrals. Despite generally positive attitudes towards the Programme, many staff felt they had insufficient information to describe it accurately to patients, which may impact both offering and acceptance of referrals. Strong leadership and personal staff motivation are also likely to impact referral offers. Similarly, patients were more likely to accept a referral if it aligned with their attitudes towards weight management and was offered at a time where they felt they could engage with the Programme.
Limitations
Data were available on numbers of patients referred but not on numbers of eligible patients not referred. All patients interviewed had accepted referral to the Programme: we were unsuccessful in our attempts to recruit patients who had declined referral. No patients from minority ethnic groups volunteered to be interviewed.
Conclusions
There is a considerable variation between case study sites in the details of how they have implemented new pathways for referring patients to the National Health Service Digital Weight Management Programme. These differences likely reflect varying local contexts. No single best model for the referral pathways has been identified.
Future work
It would be desirable to capture the experiences of patients from diverse ethnic backgrounds and from patients who declined referral. Larger, longitudinal and observational studies could help understand the specifics of referral conversations as well as the effectiveness and cost-effectiveness of these referral pathways against other pathways to the Programme to aid decision-making and development of support materials for staff.
Funding
This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR167932.