Learning from across WPs has refined our programme theory through a realist-informed approach (supporting evidence statements and context are provided in Appendix 2). We are therefore able to provide a list of recommendations for policy and practice that are aligned to the optimisation of programme outcomes and delivery mechanisms for each stage of the programme. Recommendations are provided to cover areas that either require strengthening, more universal provision across all providers, or new material/action to address specific evaluation findings.
Pre-referral
Desired outcomes
All eligible patients are identified, and the SPs develop evidence-based person-centred LCD programmes that meet the NHS service specification and incorporate current best practices and evidence.
Mechanisms required to achieve outcomes
- All eligible patients are made aware of the programme, with framing as a positive opportunity.
- The LHS has the capacity and resources to proactively support equitable mobilisation.
- Referrers have the adaptive capacity, capability, opportunity and motivation to refer equitably and effectively.
- Providers engage with LHSs to mobilise the programme.
- Providers co-develop their programme content with target populations to enhance person-centredness and resource tailoring to meet population needs.
- Providers develop their programme based on the NHS service specification and best practice evidence and theory.
Recommendations
- Providers should provide feedback on service users’ progress to primary care, to maintain awareness and impact of the programme across primary care.
- Providers should further develop the cultural competency of their service and communication of this to target populations.
- Develop and distribute more service user-facing information about the programme and what it involves. This should be delivered through a variety of communication channels, languages, and targeted at a range of health and language literacy levels to maximise reach and engagement with all eligible populations.
- NHSE should regularly review eligibility criteria, to ensure maximal reach and impact and ensure this is effectively communicated to all referral staff, to ensure it remains in line with the latest available evidence, and everyone who may benefit if provided with the opportunity.
- Local health systems need to ensure that all referral staff understand the programme and are confident in the referral process and deprescribing practices, in order to deliver appropriate person-centred referrals to the programme.
- Local health systems need to consider increasing opportunistic touchpoints raising awareness of the programme and widening out referrals to a range of healthcare professionals such as practice pharmacists, in order to help increase access and uptake across broad and diverse communities.
- Local health systems need to work together with primary care to develop (and keep updated) an equity impact assessment, to ensure that processes are in place to ensure referrals are equitable and reflect the demographics of the local eligible target population.
- Providers include a health psychologist in the programme development and training delivery to enhance the uptake and fidelity of behaviour change techniques across the programme.
- Explicit behavioural theory should be used in programme design, and evidence of its implementation should be a requirement of future NHS commissioning processes and ongoing service development.
Referral
Desired outcomes
All eligible patients are offered a referral to the programme, and the demographics of patients referred reflect the sociodemographic of the target local population.
Mechanisms required to achieve outcomes
- Service users have the capability, opportunity and motivation to take part in the programme.
- The referral process is person-centred.
- Referrers have the adaptive capability, opportunity and motivation to refer effectively and equitably.
- Providers work proactively with referrers to support effective, equitable referrals.
- Local health systems develop referral opportunities that are appropriate for their local population.
- Effective communication and collaboration occur across all stakeholders involved in the referral process and LHS.
Recommendations
- All referrers provide consistent person-centred information about the programme so that every service user has the same detail about the programme at the point of referral, with additional detail provided for those who may require it (e.g. patients with low language or health literacy).
- Any mental health concerns are noted at the point of referral and managed as appropriate while on the programme.
- Referral staff recognise the importance, and include the assessment, of, patient-reported outcome measures in engaging patients in the programme.
- Referral opportunities should be equal across all referring practices.
- All eligible patients should be offered a referral, which could be facilitated by widening points of referral across different community settings (e.g. such as GP pop-ups in community venues).
- Referral data should be continually monitored by the LHS to ensure equality in access and uptake, and targeted referrals considered where equity improvements are required.
- Providers and referrers should work together closely to streamline the referral process.
Initial assessment
Desired outcomes
All referred patients attend their initial individual assessment and start the programme, those starting the programme reflect the sociodemographics of the local population.
Mechanisms required to achieve outcomes
- Service users understand the programme, what it involves and any medication changes required, irrespective of language or health literacy.
- The programme is acceptable to all potential service users.
- Providers have the necessary system and processes in place to facilitate successful on boarding/initiation of the programme to all eligible participants.
- Providers have the adaptive capability, opportunity and motivation to support service users and provide a person-centred approach to onboarding.
Recommendations
- Providers undertake further work to improve the uptake of service users aged 50–65 years, and of different ethnicities who are less likely to start TDR.
- Where possible, providers match coaches to service users who share similar cultures or ethnicity, to help improve uptake.
- Providers should ensure that all service users acquire a comprehensive understanding of the programme – some may need more support than others to understand the programme, which needs to be accommodated.
- Providers should ensure that every service user understands any required medication changes that were provided by their referrer.
- If possible, offer service users the chance to access different models of delivery, so that the delivery model can be optimised to their preference.
- Providers should ‘on board’ service users within a time frame agreed with the service user.
- All service users should be provided with access to programme information before the start of the programme.
- Providers or primary care should screen for emotional and disordered eating and have the capacity to appropriately manage the outcome of these screening measures (i.e. there needs to be support in place or appropriate referral mechanisms for ongoing care).
- Providers need to understand the sociodemographics of their service user population, and demonstrate the additional support in place for those groups that are less likely to complete or succeed on the programme.
Total diet replacement
Desired outcomes
All service users adhere to and successfully complete TDR, lose weight and improve glycaemic control. There are no sociodemographic differences in outcomes and all comorbidities and side effects are effectively monitored and managed.
Mechanisms required to achieve outcomes
- Service users understand how to successfully complete the TDR stage, irrespective of health or language literacy.
- Family support is actively encouraged and access to peer support is facilitated.
- Mental health challenges and unexpected life events are appropriately supported.
- Service users are able to undertake medication changes and monitor blood pressure (where required), blood glucose and weight.
- Service users develop positive management strategies to undertake the programme.
- TDR session delivery is person-centred.
- Providers have the necessary systems and processes in place to facilitate successful session delivery, support and provision of TDR products/monitoring equipment.
- TDR products work for all service users (i.e. variety, taste acceptable, manage hunger, no or managed side effects).
- TDR dietary adaptation (i.e. the use of non-starchy vegetables and techniques to adapt products to palette preferences) is person-centred and accommodates any dietary intolerances or cultural requirements.
Recommendations
- Providers offer a range of TDR products to appeal to a wide range of palettes, and enable service users to taste products before ordering, to avoid situations where lack of suitable TDR prohibits programme adherence.
- Providers provide consistent guidance on the inclusion of non-starchy vegetables.
- Providers ensure TDR products are delivered regularly in small quantities to avoid storage issues and provide the flexibility for service users to change products.
- Providers need to ensure all information and behaviour change content are relevant to TDR, and as specified by NHSE.
- Providers should be aware of different cultural and religious events that may impact service users’ compliance during TDR and provide tailored support and management strategies towards continued adherence during significant events.
- All programme delivery needs to be more person-centred, i.e. adaptive and flexible to individual service user needs and literacy levels.
- Providers need to be proactive in translating resources for service users who do not have English as their first language and move the onus away from service users to find family support for translation.
- Providers should acknowledge the importance of family and peer support and provide more tailored behaviour change support to help service users overcome some of the social and cultural barriers that can occur at mealtimes and family/peer gatherings.
- Providers should offer peer support groups and consider using mobile applications such as WhatsApp.
- Providers should ensure that all programme materials are provided to service users prior to the first TDR delivery session.
- Providers should provide support and/or signposting for service users with mental health concerns and/or emotional and disordered eating.
- Providers need to be contactable out-of-hours and coaches enabled to provide more responsive support on a person-to-person basis.
- Discharge procedures within the service specification require review to ensure service users are not penalised for life events, and provider staff are trained in compassionate discharge procedures.
- Consideration should be given to providing additional glucose monitoring strips, which should be provided where service users wish to undertake additional monitoring to enhance compliance.
- Processes to streamline the collation of service user measurements should be undertaken, particularly for digital and remote delivery, where there is a reliance on self-reported data collection.
Food reintroduction
Desired outcomes
All service users are able to adhere to and complete the FR stage (including coming off TDR completely). All service users retain or continue weight loss and improved glycaemic control. There are no sociodemographic differences in outcomes, and all comorbidities and side effects are effectively monitored and managed.
Mechanisms required to achieve desired outcomes
- Service users understand how to successfully complete the FR stage, irrespective of language or health literacy.
- Anyone with emotional or disordered eating receives the support needed to enable them to adhere to and complete FR.
- Service users have appropriate peer/family support.
- Service users are able to buy, store and cook culturally appropriate, affordable and healthy foods.
- Service users are able to undertake medication changes and continue to monitor blood pressure (where required), blood glucose and weight.
- Service users have opportunities to be physically active, without cultural, financial or environmental barriers.
- Service users develop positive management strategies to undertake the FR stage and expectations around weight change.
- FR session delivery is person-centred.
- Mental health challenges and unexpected life events are appropriately supported.
- Providers have the necessary system and processes in place to facilitate successful session delivery, support (to facilitate implementation within everyday life) and provision of TDR products/monitoring equipment.
Recommendations
- Providers should work with local communities and utilise existing literature to tailor resources, such as the use of ethnic-specific Eatwell guides, and culturally tailored recipes and meal plans.
- Delivery staff should all receive cultural competency training which considers social, cultural, environmental and socioeconomic factors to optimise effective FR delivery.
- Delivery staff should receive training and resources to support service users with emotional or disordered eating and psychological support needs.
- FR delivery should be person-centred incorporating flexibility and understanding of individual circumstances.
- Some service users may benefit from more frequent and intensive support sessions and additional structured meal-planning resources during FR.
- Providers should acknowledge the impact of social stressors and life events and build flexibility into session attendance to accommodate this.
- Providers need to be contactable out-of-hours, and coaches enabled to provide more support on a 1 : 1 basis, given the heightened concern experienced by many during FR.
- Discharge procedures within the service specification require review and staff require training about how to handle discharge in a sensitive compassionate way.
- All providers should provide electronic and paper copies of diet and cookbooks or resources that can support service users, to avoid inequities generated by a reliance on service users’ ability to purchase recommended supporting resources.
Weight maintenance
Desired outcomes
All service users complete WM and maintain weight loss and improvements in glycaemic control and remission (where achieved). There are no non-biologically driven sociodemographic differences in outcomes, and service users are equipped to sustain behaviour change over the long term. There are no ongoing adverse events (physical or psychological), and service users are discharged into suitable monitoring and ongoing lifelong person-centred care. Programme is cost saving to the individual, and local and national health systems.
Mechanisms required to achieve desired outcomes
- Service users are empowered to become effective self-managers to maintain long-term behaviour changes.
- Service users have appropriate peer/family support.
- Service users eligible for a rescue package are made aware of it, and receive it if required.
- Service users are able to buy, store and cook healthy, culturally appropriate foods.
- Service users are able to build physical activity into everyday life, without cultural, financial or environmental barriers.
- Service users understand the process for continued monitoring and ongoing support.
- Anyone with emotional or disordered eating or psychological support needs receives the tailored support to enable them to successfully adhere to and complete WM.
- WM session delivery is person-centred.
- Providers have the necessary system and processes in place to facilitate successful session delivery, support and ongoing monitoring.
Recommendations
- Providers acknowledge the impact of social stressors and life events and provide flexibility in session attendance to accommodate this and enhance retention rates.
- Providers inform referrers of service user progress, providing a feedback loop to inform ongoing support for the service user and to increase engagement with referral staff and encourage the successful referral of other patients.
- Providers monitor the use of ‘off-programme’ TDR products, and support service users to achieve WM without an ongoing reliance on TDR.
- Providers acquire a deeper understanding of culturally specific foods, understanding the cultural influences that affect dietary choices and social support within families and communities of diverse ethnic groups.
- Providers include ongoing continued professional development on cultural competency and health literacy.
- Providers develop language-specific support groups and consider incorporating interpreters into programme delivery.
- Providers ensure ongoing support or signposting is provided for service users who experience mental health concerns, or emotional and disordered eating during WM.
- Providers consider providing more frequent sessions and/or out-of-session support to facilitate adherence and completion of WM.