Taking control

Fit for Life is a model obesity service in which physios help people to self-manage their weight and associated conditions. Gill Hitchcock reports.

Service user Keith Mills with specialist weight management physio Anna Young

Step off the busy A12 in east London’s Tower Hamlets into one of the borough’s quieter streets and you’ll find the Bromley by Bow Centre. The 1960s building sits alongside a small park – rare greenery amid the urban sprawl – and is fronted by a courtyard with a small fountain and sculptures. Each week staff in this inviting environment help people to gain skills, find work and improve their health. 

It’s the base for Fit for Life, a programme run by the Homerton University Hospital NHS Trust and commissioned by Tower Hamlets clinical commissioning group (CCG). It aims to support adults with a body mass index of more than 35 and associated long-term conditions to self-manage their weight and improve their health. 

Anna Young, the specialist weight management physiotherapist with Fit for Life’s multidisciplinary team of psychologists and dietitians, says: ‘There are a lot of health conditions there that physiotherapists can help people manage through increasing physical activity, education and just supporting people back into moving more. Things like heart conditions, or respiratory conditions such as obstructive sleep apnoea, high blood pressure, arthritis, chronic back or joint pain and fibromyalgia.’ 

Following a referral from their GP, Ms Young assesses clients’ needs relating to physical function and helps them to identify lifestyle changes that will lead to weight loss and better health. People are then invited to join a programme of 12 weekly two-hour sessions. The first hour is dedicated to psychology, dietetics or physical education, followed by a second hour of exercise. This might be walking, Pilates, circuit training, or a class designed by the clients themselves – all geared to provide a taster of different ways to be active. 

Long-term investment

Meanwhile, each person is assigned a case worker. If, say, they need extra input from the physio or psychologist, the case worker will help identify that. And when the 12-week programme is over, people are offered a ‘maintenance phase’ of support over a further nine months.

‘People can make changes in a short period, that’s the easy bit,’ says Ms Young. ‘But it’s not easy to keep it up. That’s where people struggle and where the investment needs to be.’

Simon Stevens, NHS England’s chief executive has called for a ‘radical upgrade’ in public health and prevention, not only to benefit individuals but because the future financial sustainability of the NHS depends on it. He promised that the NHS will back ‘hard-hitting national action’ on obesity and other major health risks.

There are relatively few ‘tier 3’ services like Fit for Life offering specialist weight management services in England. Fewer still offer physiotherapy as an intrinsic component, perhaps, in part, because there’s an acute shortage of physiotherapists specialising in this field, says Alan Myers. A bariatric physiotherapist at the Homerton who has also worked with Fit for Life, Mr Myers says: ‘I suppose it’s the history of weight management coming from dietetic and psychological realms and that the value that physiotherapy can bring hasn’t been fully recognised.’ 

He believes in a multidisciplinary approach to weight management, however, saying: ‘Often when people have put on a lot of weight, are deconditioned and have associated health conditions, that’s happened over a long period of time.

‘There are usually a multitude of reasons. There may be some psychological issues, or some trauma in the past. But the evidence shows that if you manage this as a multidisciplinary team the effects are much greater.’

Stigma and discrimination are huge issues for many in Ms Young’s client group. They feel embarrassed about their weight and lack people to talk to about this issue, much less get practical advice and support. She is particularly disappointed at the level of bias among healthcare professionals who are unable to empathise with this group. 

Mr Myers adds: ‘There is a favourite quote of mine from Professor John Wilding, who heads up the Aintree weight loss service in Liverpool, that to tell an obese person to lose weight is like telling a depressed person to be happy. It’s over-simplifying a very complex situation.’ 

Turning point

Two service users, who are now at the ‘maintenance’ stage of the programme, made good ambassadors for Fit for Life when Frontline visited. After a muscle injury in 2014 left her on crutches, Charmaine Humphries gained 57kg (about 9st). She thinks Ms Young’s approach helped her lose weight and regain her mobility, saying: ‘She made me feel safe, which was something I hadn’t felt with other physios. And she made me understand what was going on with my leg, my body and from a mental state of having to adjust to carry all this new weight.’

On his way to an exercise group, Keith Mills says he had been disabled by crippling back pain and resorted to overeating as a ‘comfort thing’. But he says the service was a ‘turning point’ and that he has lost 16kg (about 2st 7lb). His says his early experiences of services were disappointing, but likes the way that Fit for Life allows him time to discuss his issues with specialists and with people with similar problems. ‘I found all aspects very helpful, but especially the physiotherapy because I was having lots of problems. I would only walk for about 10 minutes and my leg would stop working,’ he says.

Fit for Life celebrated its first birthday last month. It is contracted to provide services for Tower Hamlets for a further year, and has started receiving referrals from Waltham Forest CCG under a two-year arrangement. Perhaps surprisingly, the Homerton trust’s home borough of Hackney does not yet offer tier 3 specialist weight management services. 

Gathering evidence

Fit for Life has a complex client group and measuring success is hard. However, the service provides feedback to the Tower Hamlets commissioners. It submits monthly or quarterly data on people’s weight loss and waist circumference, and the results of psychological tests about depression, anxiety or self-esteem. Clients do fitness tests, complete questionnaires about diet or behaviour change, and rate their satisfaction with the service. Case reports are important because they can highlight aspects that cannot be measured. All this goes to the CCG.

‘The data is really rich,’ Mr Myers says. ‘It can show how if you affect one member of a family unit, there is a knock-on effect for their spouse, children or older members of the family. I had one patient, an orthodox Jewish man, who came to my classes, really enjoyed them and set up his own version for the orthodox Jewish community up in Stamford Hill.’

Ms Young describes weight management as a ‘hot topic’. Public Health England says that two adults in three are overweight or obese and predicts this will reach seven in 10 by 2034. It puts the cost to the overall economy at a staggering £27 billion annually. The cost to the NHS is said to be £6.1 billion, while the cost to social care is £352 million and obesity-related sick leave from work is said to cost £16 million.

Funding tier 3 weight management services is a problem while another, according to Ms Young, is a lack of research on  what constitutes an accepted ‘gold standard’ in provision. ‘Teams are constantly looking at new ways to engage people and help with success. It’s an ever-changing and evolving beast and everyone has different needs and ways of responding to our help. We have to flexible and creative at times.

‘It’s a real challenge, but as a physio it’s a brilliant job because you get to use all your skills and manage people holistically, which is so much more rewarding.’ fl

Anna Young is keen to develop a network of physiotherapists working in weight management to share evidence, information and experiences. Contact Anna via email: anna.young@homerton.nhs.uk.

Gill Hitchcock

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