Defining Quality of Service

Obesity in primary care has become an increasingly common problem. Like any other medical condition overweight and obese patients should have access to appropriate treatment and care using a delicate, understanding and non-judgemental approach. Weight loss in primary care is of interest for the purposes of improving a person's quality of life. During the study the author will explore the prevalence of obesity using the geographical trust region with a population of 158,000 (Office of National Statistics (ONS) 2007) in comparison with the town centre based practice where the author works as a trainee nurse practitioner. The practice has a mixed socioeconomic, predominately (95.53%) White British population of 15, 186 (Annual Public Health Report 2008). Local authority with in which the author works has been ranked as 49th most deprived out of the 354 local authorities in England in 2007 in the Index of Multiple Deprivation 2007 (IMD 2007). Although obesity is increasing at the same rate in all social classes, the prevalence of obesity is higher in lower socio-economic groups, particularly in women (Henderson and Gregory 2002).

The National Institute for Health and Clinical Excellence (NICE) developed guidelines on identifying and treating obesity in 2006 following on from the Scottish Intercollegiate Guidelines Network (SIGN 1996), this in turn along with Primary care service Framework 2007 has lead to Health Care Professionals looking at ways to gain the background knowledge, provide and implement a service to deliver integrated obesity management enabling patients to change their eating and activity habits and motivate obese individuals to lose weight, maintain weight lose and increase fitness in accordance with the White paper (2004). It is also thought that additional training in behavioural counselling maybe vital when assessing a patient's readiness to accept change (Drummond 2000). Individuals who are not emotionally ready to tackle the issue of lifestyle changes are more likely to fail.

Dealing with obesity in the practice setting can be achieved by setting up specific lifestyle clinics dedicated to offering support and advice to patients who wish to lose weight or maintain a healthier lifestyle looking specifically at behaviour change. This clinic can run alongside or in conjunction with existing chronic disease and routine Health check clinics with self referral or healthcare professional referal. By helping the patient look at how unhealthy behaviours can be an element of their lifestyle and daily choices (see table 1) it is possible to suggest ways in which to change in a mutually agreed plan of care.

Awareness and knowledge of what change is required and why, are fundamental first steps in enabling change to occur. Motivation is an essential part of nearly everything we do. Regular reviews can provide motivation and change behaviour through incentives and penalties. Personal factors, such as individuals' self motivation, drive and desire to improve their appearance and health are also important. Target and objectives can influence how much people want to change but their priorities and commitments may also obstruct their ability to change.

Change to clinical practice can only be successful if the reasons for introducing the change are clear, compatible with current practice and ideas and the process is planned carefully in advance (Davis1999). Change theories share common factors. To ascertain behavioural change, according to these theories, patients need the desire to make a change, have the ability to make the change, believe that they will have a better quality of life if they make the change, believe that the change is "right for them," and discover how and when to make changes.

Obesity management needs an integrated approach involving a multi-disciplinary team of Healthcare Professionals. General Practice is an ideal starting point to influence and initiate management strategies. Healthcare professionals need better training and access to management programmes that include dietary advice, physical activity and behavioural change if they are to initiate the policy effectively. For the programme to succeed the patient needs to be the central component. Obesity does not lend itself to the classical medical model where the condition is diagnosed, treatment prescribed and then the professional responsible for the outcome. It is ultimately the patient who is in control over their decision to proceed and succeed. Weight lose/maintenance is not easy for obese/overweight patients, many of whom have already tried and failed in controlling their weight. It is the role of the primary care team to support and encourage weight management and lifestyle change. In an attempt to achieve these changes in behaviour management are vital.

Eating and physical activity are human behaviours which can be modified even though they are predisposed by a complicated set of factors. If in practice the overweight/obese patient was identified and advised of the fact, they simply wouldn't care. Consultation with the patient and establishing if they recognise they have a weight problem using a sensitive and respectful manner is the first essential step to change. It is then possible to produce a plan of action involving providing information and eliciting the patient's views about their weight as well as details about their weight history and any previous attempts at weight loss. The early stages of consultation are about building a rapport with the patient through active listening. Communications skills are essential to implement a behavioural approach effectively (NICE 2007). Professionals should also have the ability to express consideration, build self-belief and provide clear, structured and relevant information.

Raising the issue of lifestyle changes can be extremely difficult to talk about as the patient may feel uncomfortable and they may feel responsible. This could have a negative effect on the patient-professional relationship (Drummond 2000). As a professional it can be maintained that we have a duty of care to discuss the importance of a behavioural approach in managing obesity and its practical application in helping overweight patients achieve and maintain behavioural changes. Pearson 2003 suggests that 'linking weight to a current health concern is often an appropriate way to introduce weight management issues'. Advice should be individualised to condition and patient.

By providing the patient with the appropriate information to help them make informed decisions about their health behaviour is part of the professional role. By individualising programmes to assist/support patients in changing their lifestyle for good can give them the incentive to lose some weight or prevent further weight gain. There is always the risk at this point that the patient will abandon the

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