The document outlines an integrated approach to obesity and weight management in Nottinghamshire, detailing challenges in commissioning and modeling under the new local public health structure post-2013. It emphasizes the need for a whole system approach, incorporating various intervention levels and the importance of accurate data modeling to estimate needs and outcomes. The document also highlights the use of a scenario generator for effective modeling of patient pathways and management, ultimately aiming to address the growing prevalence of obesity in the region.

1. Modeling an Integrated
System for Obesity and
Weight Management
David Gilding
Public Health Information and Intelligence
Nottinghamshire County Council
Anne Pridgeon, Policy lead
Nottinghamshire County Council

2. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
1 800 547 6024 | +44 141 552 6888
Presenters
David Gilding
Public Health Information and Intelligence
Nottinghamshire County Council
David.Gilding@nottscc.gov.uk
Claire Cordeaux
Executive Director, Healthcare
SIMUL8 Corporation
Claire.C@SIMUL8.com

3. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Housekeeping
• Audio
• Q and A
• Recording available on
simul8healthcare.com

4. Nottinghamshire County
4
Population approx. 780,000 people. Some areas are very affluent, others deprived.
Parts of Bassetlaw, Newark and Sherwood very rural – others ex-coalmining
Conurbation around Nottingham City.

5. The National Health Service & Public health
Background
• Prior to 2013, obesity and weight management was the responsibility
of Primary Care Trusts (PCTs)
• These were NHS organisations who commissioned – not provided –
care
• The local Public Health system was part of PCTs
• In April 2013, local Public Health transferred to local Government
5

6. Changes to NHS & Public health
April 2013
6
LAP
H

7. Changes to NHS & Public health
Who commissions obesity and weight management?
7
LAP
H

8. Obesity and weight management – tender and procurement process
Challenges
• Nottinghamshire has adopted a whole system approach
• one tender for prevention and all levels of intervention and
treatment for all aged over 5.
• Focus on pregnant women
• We also want an outcomes based commissioning approach
• Parts of the system are commissioned through national specialist
commissioning functions
• Each of these has implications for modelling and simulation
• As far as we know, no other LA has commissioned on this basis
8

9. Obesity and weight management – tender and procurement process
9
A whole system approach

10. Obesity and weight management – tender and procurement process
10
Weightwatchers,
Slimming world,
Rosemary Conley etc
‘We’ll help you lose
weight’
GPs
‘You need to lose 7
kilos’
Who can I
refer to?
Exercise referral
schemes
We can help you
exercise more - if you
live locally
Bariatric surgery
Demand is much
greater than capacity
Who’s
going to
pay?
Specialist treatment
Who is responsible?
Who will pay?

11. Obesity and weight management – tender and procurement process
11
Weightwatchers,
Slimming world,
Rosemary Conley etc
‘We’ll help you lose
weight’
GPs
‘You need to lose 7
kilos’
Who can I
refer to?
Exercise referral
schemes
We can help you
exercise more - if you
live locally
Bariatric surgery
Demand is much
greater than capacity
Who’s
going to
pay?
Specialist treatment
Who is responsible?
Who will pay?Public Health
Rising prevalence overweight and obesity
Dispersed and disjointed services
No system leadership
Long-term health consequences

12. Obesity and weight management – tender and procurement process
12
Weightwatchers,
Slimming world,
Rosemary Conley etc
‘We’ll help you lose
weight’
GPs
‘You need to lose 7
kilos’
Who can I
refer to?
Exercise referral
schemes
We can help you
exercise more - if you
live locally
Bariatric surgery
Demand is much
greater than capacity
Who’s
going to
pay?
Specialist treatment
Who is responsible?
Who will pay?
Commission a whole
system approach

13. 13

14. 14

15. Modelling challenges
• Estimate need
• Children aged 5 to 17, adults aged 18 or older, pregnant women
• Build a NICE compliant model
• How to commission affordable numbers of clients, given no precedent
for this pathway
• Clients are likely to be in the system for up to 2,3,4 years;
• how will this affect provider stability, payments and cashflow
(provider and commissioner)
• arrangements at end of contract
• How might successful, sustained weight loss by individuals affect
prevalence of overweight/ obesity in Nottinghamshire?
15

16. Obesity and weight management – tender and procurement process
16
Estimating need

17. Estimating need
• We don’t have counts of obese and overweight people
• Need to estimate from national and regional surveys and estimates
• This is even harder when talking about health need as one
part of obesity & overweight
• We need an overall idea of scale
17

18. Estimating need – changing obesity profile in England
18

19. Hypertensive Not hypertensive
BMI category Low High Very high BMI category Low High Very high
Under 2,121 0 0 Under 7,695 0 0
Normal 36,369 8,247 1,265 Normal 148,597 34,648 5,381
Overweight 14,523 25,574 22,918 Overweight 39,973 71,202 65,272
Obese 1 (30to35) 0 6,338 58,342 Obese 1 (30to35) 0 3,324 38,895
Obese 2 (35 to40) 0 0 23,262 Obese 2 (35 to40) 0 0 12,525
Obese 3 (40+) 0 0 11,416 Obese 3 (40+) 0 0 4,893
Waist Waist
All
Increased risk 85,725
High risk 94,171
Very high risk 178,589 of whom BMI>=40 16,309
'Pathway eligible' 358,485
Obesity and overweight vs health risk
NICE ‘health risk’ categories
• Waist circumference as risk factor
• Comorbidities as risk factor
• 3 categories: increasing, high and very high risk
Nottinghamshire numbers:

20. Hypertensive Not hypertensive
BMI category Low High Very high BMI category Low High Very high
Under 2,121 0 0 Under 7,695 0 0
Normal 36,369 8,247 1,265 Normal 148,597 34,648 5,381
Overweight 14,523 25,574 22,918 Overweight 39,973 71,202 65,272
Obese 1 (30to35) 0 6,338 58,342 Obese 1 (30to35) 0 3,324 38,895
Obese 2 (35 to40) 0 0 23,262 Obese 2 (35 to40) 0 0 12,525
Obese 3 (40+) 0 0 11,416 Obese 3 (40+) 0 0 4,893
Waist Waist
All
Increased risk 85,725
High risk 94,171
Very high risk 178,589 of whom BMI>=40 16,309
'Pathway eligible' 358,485
Obesity and overweight vs health risk
NICE ‘health risk’ categories
• Waist circumference as risk factor
• Comorbidities (especially diabetes, high blood
pressure) as risk factor
• 3 categories: increasing, high and very high risk
Nottinghamshire numbers:

21. Obesity and weight management – tender and procurement process
21
Modelling
hypothetical pathway (s)

22. Obesity and weight management – modelling challenges
• Build conceptual models based on NICE guidance
• One for children aged 5 to 17
• Another for adults of any age
• Pregnancy
• These need to identify ‘successes’ in terms of successful outcomes
(to facilitate an outcomes based approach)
22
Success for individual clients means:
• Improved dietary intake
• Improved physical activity
• Improved mental health and wellbeing
• Sustained weight loss (adults, not pregnant)
• Appropriate weight maintenance or loss for
children & young people

23. LWM: lifestyle weight management
Assess Tier
2
Assess Tier
3
LWMSuccess
LWMSuccess
LWM
Not success
Specialist
team
Orlistat
Not Orlistat
Success
Follow-up
Not success
Discharge
Bariatric
assessment
Not eligible
or decline
Follow-up
Surgery
2-year
follow-up
LA follow-
up
Bariatricassessment,surgery
&2-yearfollowupnotinscope
Service entry
In scope Out of scope
Schematic of adult pathway used for modelling
This is a hypothetical, NICE compliant pathway that Nottinghamshire County Council has developed;
your pathway may differ
23

24. Simulation of the pathway
24
Decided to use Scenario Generator
• Previous experience
• Good tool for modelling strategic pathways
• Includes ‘time-in-step’ and ‘time-in-system’ measures
• Can ‘loop’ pathways – cyclic systems
• Discrete event methodology matches individuals moving through
a system
• Access to ‘raw’ results data
• Graphical approach; easy communication

25. 25
Scenario Generator model

26. 26
Scenario Generator model
Start
Very
high
need
High
need
Increased
need

27. 27
Scenario Generator model
Modelling long time-scales
Follow up after bariatric surgery
• 2 years NHS provider
• Then on to LAPH responsibility

28. Time in system
These are results of Nottinghamshire County Council modelling a NICE compliant pathway 28
Multiple ‘success’ points
over several months years:
Hard to estimate numbers
in any one month/ year

29. Time in system
These are results of Nottinghamshire County Council modelling a NICE compliant pathway 29

30. Time in system
Because it’s a complicated system, with some elements taking months to complete,
the time each client spends in the system can vary considerably.
To show this, if 1,000 adults and 1,000 children start tiers 2/3 in month 1,
we estimate that they will exit the system as follows:
Adults:
• 60% exit by end Y1
• 90% by end Y2
• A few into Y4
• Tiers 2 and 3 only
CYP:
• 71% exit by end Y1
• 100% by end Y2
• Tiers 2 and 3 only
These are results of Nottinghamshire County Council modelling a NICE compliant pathway
NumberofexitsNumberofexits
30

31. Patients in system – different pathways
If we assume a constant number of adults and CYP starting each month,
then the estimated profile of patients in the system each month is as follows
These are results of Nottinghamshire County Council modelling a NICE compliant pathway; your pathway may differ31

32. Patients in system – all pathways
Estimated profile of patient / service user numbers: adults and CYP in tiers 2/3, maternity and post-bariatric support
These are results of Nottinghamshire County Council modelling a NICE compliant pathway
Our modelling suggests that patient numbers - and provider activity – will peak in Y4 of contract
32

33. Conclusions
33
• Successful tender awarded in December
• Service live from April 2015
• Assurance for commissioners
• Provider appreciates the detailed modelling
• Volumes flow over long-term
• Anticipate end-of-contract effects
• Shared risk: ‘all models are useful, no models are right’
• Scenario Generator was a useful tool in the modelling process
• But we expect available resources far outstripped by demand…

34. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
QUESTIONS
Please forward any topics you would like to
see covered to claire.c@SIMUL8.com
Continue the discussion on SIMUL8 in
Health – LinkedIn Group