What is interesting and unique about the service at SWB is their 'Roving Bariatric Service' team travels to patients in their own specific regions instead of patients travelling to them. The SWB Group cover a vast area in the southwest from Plymouth, Bournemouth and Cornwall right up to Bristol. Wheeler explained that the move to nurse and dietician led follow-up has freed up time for the surgeon so they can concentrate on surgical issues and has made best use of the multi-disciplinary team (MDT) time.
The surgical team has instilled a great confidence in the nurse and dietician decision-making process by handing postoperative affairs to them. “When patients are initially seen for surgery they come to nurse led follow-up and are seen on a one-to-one basis. All patients are offered a free consultation where a patient can come and discuss their situation and suitability for surgery,” explained Wheeler. “Following this, patients are then seen by the surgeon, dietician and anaesthetist to finalise their suitability for surgery.”
She said they pride their service on having surgeons that are not only easily approachable in their manner, but are easily accessible and available to the wider team and their patients (ease of accessibility could be any postoperative medical or surgical issue). Such is the nature of the MDT, it is made up of 15 healthcare professionals including: surgeon; dietetic; nurse and psychologist, as well as a ‘fantastic’ administrative team.
Wheeler claims that by making a greater investment in time with patients postoperatively, outcomes in patient expectation for both gastric bypass and gastric band have improved significantly. “Patients tell us that through the transition phase following their procedures having someone readily available to talk through and discuss the different stages is invaluable whilst they are adjusting”, she said. “This is a huge part of our care pathway in trying to continually improve the patient experience.”
Gastric band patients
For gastric band patients the priority is ensuring their expectations are managed by guaranteeing that the emphasis is taken away from the actual gastric band fill.
“We gear our practice towards supporting patients in making both short-term and long-term changes working closely with them on the practicalities of supporting patients to make the appropriate changes for health and postoperative living,” said Wheeler. “We actively encourage patients to include a wide variety of foods in their diet as well as working with them on their behaviour change as well as supporting good food choices for health”.
By removing the focus away from band adjustments, patients take responsibility for their progress and not rely solely on adjustments, which may inevitably be inappropriate and do nothing to support their long term lifestyle change, she claims. The priority in the early stages is to work really closely with patients to manage expectations for when they come to clinic.
Particularly with band patients, the team found that since working with the nurse and dietician lead follow-up format, patients no longer come to clinic 'expecting a fill' or to see the surgeon again, but instead arrive for their review on the understanding that the onus is on them to make the changes needed to get the maximum effect from working with their gastric band A primary focus in the initial months following surgery and moving forward is always moving patients towards nutritionally balanced and varied foods incorporated into the diet, and working on supporting the necessary changes needed to make this happen.
“We focus primarily on the basics for eating healthfully, supporting patients to eat regular meals and working with them so they understand that working with particular textures of food can greatly influence their progress,” she said. “We also assist patients with learning about their own behaviour patterns creating better awareness to support them in moving away from potential sabotaging snacking behaviour.”
Whilst the standard follow-up appointment at six weeks post-operative for patients is in place so that detailed dietary advice and behaviour change can be implemented, Wheeler plans to introduce dietician input sooner (via phone contact) within that initial six-week period post-operatively. Wheeler explains that traditionally patients have always had contact with the nurse in the early weeks, but now they are looking at incorporating contact with patients with the dietician within those first few early weeks as they feel this will further support patients before they even come to the clinic in the early weeks.
Changes in lifestyle Patients are followed up long term and the emphasis is very much focused towards a gradual process of change with sustained weight loss and improvement in health benefits working on a slow, gradual weight loss over a period of time focussing on eating quality.
“We want people to lose weight but equally as important, we want to ensure that safe steady weight loss is achieved together both in the short and long term, with the appropriate behaviour change in eating practices and good food choices achieved,” Wheeler stated. “We are finding that this approach particularly with bypass patients is having excellent results, it's these patients we want to ensure don't fall into difficulties further down the line as they have relied solely on their surgery for the changes in their weight.”
“We focus primarily on the basics for eating healthfully, supporting patients to eat regular meals and working with them so they understand that working with particular textures of food can greatly influence their progress” Anne Wheeler
Therefore, the team works on an ethos that means they support patients to continue with their change in lifestyle for the long term, not just so that they achieve their weight loss goals but equally as importantly they manage to maintain this. The focus is on the quality of what they are eating to achieve a healthier weight. This can be using dietetic practices such as experimenting with different foods, incorporating a variety in their diet, supporting them with practical support with recipe ideas and meal plans, as well as getting patients to achieve the right amount of fluid on a daily basis for them.
“Many of the patients are not able to focus on too much information front end so we do not bombard them with information overload at this at this stage, instead we now invest a great deal of time with them for as long as is needed postoperatively,” said Wheeler. “This is to work through the transitional changes for immediate and long term changes, which is working wonders with our patients as is evident in the feedback from patients that is given.”
“One of our greatest strengths lie in the differing personality types of the MDT which we find invaluable when relating to the varied patient group we look after. I really believe that the one of the key strengths we have as a team is being able to relate to our patients and rapport building is such a vital necessity to our work and we find our patients appreciate having the choice of being able to see someone they naturally have affinity with,” said Debra Williams, a bariatric dietician working with the team. “We find the complement in management styles within the MDT not only in cements our relationship as a team, but also goes a long way to also have that extra leverage when working with patients that are struggling."
“If ever we are in a situation where we've hit a brick wall with a particular patient in their progress, there's always one member of the team that is able to offer a different style in their delivery for suggestions,” said Wheeler. “This can often be the key to supporting a patient to 'move on'.”
She also believes having a solid and stable team provides an edge to how they work, with most able to see the same team members which is invaluable for them and appreciated. One of the advantages of the nurse and dietician led follow up programme is their 'open door policy'. Whilst all patients are reviewed six weeks post-operatively with appointments every three months, SWB operate an open door policy.
They do not have a restriction on the number of times a patient is seen in the first year following surgery and in fact positively encourage an 'open door policy' which means patients are able to gain access to the support they need.
“It may be just a five minute chat to reassure someone they are doing well, and all that is needed to help them on their journey. Our patients appreciate it and in actual fact we do not feel it takes up too much extra time. In many cases, we can actually save time by supporting patients by troubleshoot problems and often nipping them in the bud at start alleviating the need for them to escalate.”
“With our bypass patients we came to realise early on that we needed to work very hard with them individually in the first year by rehabilitating them for life long change, and we are finding that we are achieving excellent results for their long term progress meaning fewer issues with recurrent weight gain after the two year period,” added Wheeler. “The regular feedback we have from our clients teamed with our ‘open door policy’ for support means that we feel we know our patients and will continue to offer a tailor made service of value to both the MDT and our patients.”
The clinic also places value in patient support groups and actively encourages all of their patients to enrol in a local British Obesity Surgery Patients Association (BOSPA) support group. According to Wheeler, one of the reasons they work so well as a team is that professionally they have really clear guidelines as to their working practices.
“With our bypass patients we came to realise early on that we needed to work very hard with them individually in the first year by rehabilitating them for life long change" Anne Wheeler
“We have a great solid working relationship which is relaxed and devoid of any professional issues as we are clear about our professional boundaries. We work within our professional remits and work closely together for our patients and we are finding that this level of cohesive working practice helps us to not only gel well as a team but also supports in effortlessly getting the message across to our patients without added confusion.”
The team are also introducing a nutritional analysis to provide patients with a report detailing their nutritional profile, which will be used to help patients focus on the dietary changes they have made since they had surgery.
“We're finding this lends a positive focus to long term change. Rather than just focusing on weight, the nutritional analysis is something patients can actively feel a contributory level of input and responsibility, which they find is a motivating tool in the rehabilitation period during that first year,” said Wheeler. “Whilst we know it is only a snapshot of what is happening, it can help us to help patients focus on how well they are doing with practical ways they can improve their health moving forward through simple, practical but effective changes to their diet.”
Williams agrees and says this has added value to the follow up service as patients can view the nutritional analysis as a milestone, something to work towards.
“At the one-year stage when they should be settled in to their new routine, it serves as a useful reminder as to how well they are doing and how far they have come, but it also supports us as dieticians to keep the focus on promoting better nutrition for health. We work with our patients over a period of time pushing them out of their comfort zones and encouraging change moving people out of their usual pattern, which can be void of variety and imagination. We guide people with the effective use of food diaries, from how to complete them to how they diary can be a tool used to monitor their own progress. This may include support with cooking skills and practical tips or food preparation and suggestions for when a person is at work, out for dinner or socialising – these are the real needs of our patients and having a no nonsense practical approach to strategies is really helpful to our clients.”