Thirteen practice staff — nine practice nurses and four GPs — representing seven of the eight practices were interviewed. GPs were more reluctant to participate than practice nurses, explaining in most cases that they had played little or no part in the trial and therefore had no comment to make on it. Ten patients agreed to be interviewed. Data from the interviews confirmed that the obesity management model had indeed been implemented with very few patients and points to a number of inter-related factors which seem to have led to a progressive disengagement with the trial by practice staff.
Communication about the aim of the trial
This qualitative study uncovered a substantial degree of misunderstanding about whose responsibility it was to deliver the weight management model to patients in the original trial. Although the trial protocol stated that it was the responsibility of the practice staff, most of the staff interviewed believed that the research team would maintain some degree of responsibility. In two practices, nurses believed the research team would take complete responsibility for implementation and one nurse expressed her relief at ‘handing over’ the care of the patients at her practice to the research team.
Nurses at two practices described a moment some months into the trial when they received a reminder from the research team about the study protocol and realised that they should still have been implementing the model. In both cases, they believed the study to be far too far long and allowed it to ‘fizzle out.’
How this fits in
Follow-up studies that seek to understand the context and provide explanations for the success or failure of interventions under trial are rare. This qualitative study generates hypotheses concerning the practicalities of conducting research in primary care which extend far beyond those evident from findings of the original trial. It raises issues concerning the scope of the intervention and communication between researchers and practice staff. In addition it illustrates how a clinical topic can exert idiosyncratic and unexpected effects on the conduct and outcome of a study.
The perspective of participating patients
The majority of patients interviewed had no recollection of any change in treatment patterns that might have been associated with the trial: on prompting they did not recall having been seen or weighed more frequently, having behavioural targets set, nor did they recognise the dietary leaflets associated with the programme. Several patients demonstrated a good understanding of the trial protocol and — based on the perceived lack of action — assumed their practice to be in the control arm:
‘I understood that some practices would have some help and some support and other things like that, and some wouldn't have … I suppose like a placebo, you know like in a tablet study. I assume that our practice was one that didn't get an awful lot of support or help, because there wasn't a lot of feedback, or you know, “Come along on a more regular basis and get weighed”.’
Among patients that did notice a change in their care, some recalled short-term increased activity and some seeing the dietary leaflets associated with the intervention. Half of the patients interviewed lost weight during the trial follow-up period but they unanimously attributed this to reasons outside of the study.
In terms of the more general issues around weight loss, all the patients spoke of the difficulty they had trying to lose weight. When asked about the help they received from primary care they expressed concern with the seeming lack of new options for weight loss and a feeling that staff couldn't offer them anything new, concerns echoed by the practice staff (see below). The specific difficulty of understanding nutritional labelling on foods was a commonly raised issue.
Patients felt that discussion about diet was only useful when it was individualised — it was not useful to have very general healthy eating leaflets, or to discuss risk if it was not directly related to an individual. Patients sometimes felt that practice staff applied a very formulaic approach. One woman described the advice given to her overweight daughter by the GP as just ‘stop eating that, that and that’. She felt that childhood obesity has been assigned political importance but was left feeling that her practice was just not keeping up with current ideas about treatment. Another stated:
‘They just address straight away the food and give them [the patients] a diet, and that is just so wrong, it's like writing a prescription before somebody walks in, before they know their ailments.’
On the other hand, most patients seemed to have low expectations of external help with their weight; recognising that the responsibility ultimately lay with them. Many stated that they were very well aware of the principles of weight loss — about what to eat and the need to increase exercise. There was a strong consensus that unless you had the right state of mind, there was little a GP or nurse could do to help.
Staff perception of the training programme (intervention)
Almost all practice staff were positive about the format and style of the training. The resources given for use by both practice and patient received unanimous high praise, the only complaint coming from one practice which said that they had not received enough to meet patient demand.
The content of the training generated a broader range of responses. Most staff described the weight management strategies covered in the training to be a refresher of what they already knew. Two nurses from one practice were sufficiently disappointed by this that they immediately dismissed the study as a ‘waste of time’. Conversely another nurse described herself as having begun with so little knowledge that she ‘could have done with a bit more information.’ Another had found it confusing to have to apply a mathematical formula to work out an energy prescription for patients, admitting: ‘I don't think I understand it even now!’ Personal experience of weight loss also affected staff perceptions of the training, with one nurse acknowledging private doubts about whether the model could work, given her experience of ‘dieting’. She felt the ‘portions [of food] allowed were too generous’.
Significantly, a treatment algorithm — outlining the recommended steps for the implementation of the weight management model and given out at the end of the training package — was not recognised or remembered by any of those interviewed. ‘Well, that just never happened,’ was a comment representative of most participants.
Prevailing attitude of staff regarding weight management
It seems likely that practices participating in the original research had an interest in weight management. Despite this, interviews at most practices uncovered feelings of frustration towards weight management before, during, and indeed since the trial. Nurses frequently described feelings of exhaustion and hopelessness when dealing with overweight patients. Although several interviewees believed weight management should be a high priority, most felt that at their practice — and especially among GPs — it was not viewed as such. ‘Most doctors have no interest in obesity’, agreed one GP, because it is the patient's ‘personal problem’. Another GP said:
‘It's not a medical problem … we really haven't got time to address weight.’
None of the staff interviewed perceived they had any success in their efforts to help people lose weight. In the case of the practice nurses, it was clear that they aspired to respond to each new encounter positively, however, they commonly described short-term achievements with patients, relentlessly followed by weight regain. The frustration this can cause is clear in one nurse's account:
‘I'm the one that struggles with these people, trying … banging your head against a brick wall, seeing them coming back and back … lose three kilos, see them then 3 months later it's back on again.’
Staff felt they quite quickly reached the limits of their ability to help and acknowledged that the hardest thing of all was helping people to achieve long term behaviour change. In some cases they were left with negative feelings towards the patients:
‘… they'll insist they've really, really tried, they don't eat any fast food, they don't eat any sweets or chips or anything of that nature, but they don't lose any weight. So apart from insinuating that they're lying through their teeth, it becomes a stalemate, really.’
‘I probably see weight loss as a little bit tedious … I find the patients' attitudes a little bit — Give me a pill and make me thin! You come up against a brick wall. I find it quite annoying.’
Lack of time to invest in helping people lose weight has arisen in previous studies4
and was consistently raised by staff in this study. Nobody we interviewed said they'd be likely to raise the subject of weight loss opportunistically because of time constraints but also because of the fear of upsetting a patient. Similarly, the lack of options available when considering referring patients for more specialist help was commonly cited.
Several nurses mentioned the impact of the latest general medical services (GMS) contract, suggesting that it had reduced the priority assigned to weight management:
‘We've been running a weight management clinic and a slimming group … we've been seeing them here on a regular basis to weigh them and keep the support going. And the doctors have now decided it's a waste of our time — well, it's not a good use of our time. It's the GMS contract. Points do not make prizes where weight is concerned!’
This feeling that the new contract had adversely affected weight loss services was not unanimous with a nurse and GP from two different practices maintaining that it had not altered the care they offered to their patients.
Finally, around half of the staff mentioned that they found weight loss a difficult issue because they were overweight themselves:
‘I struggle at losing weight myself, so I feel such a hypocrite … and to be honest, when I have someone coming to me to lose weight, in the practice, my heart just sinks, cause I think … I'm not brilliant at this.’
Impact of clinical area on conduct of trial
Coming amid this low expectation of success, staff described high expectations of the weight loss trial. Almost all of the nurses described an initial response of enthusiasm and extremely high hopes for the intervention. However, for many this was followed by disappointment, which in some cases had a significant impact on the work of implementing the weight management model.
The main object of the nurses' hopes was for something new. Feeling, as one nurse had put it, that ‘they had nothing left up their sleeve with which to help the patients’, they hoped that the research project would provide them with different techniques with which to tackle obesity. ‘We thought it would be something new, revolutionary, to inspire us,’ said one. Others hoped a new tablet or some new weight loss advice was being developed, because in their experience:
‘… everything that's churned out in diets and weight loss always seems to basically come to the same conclusion.’
GPs seem to have had lower expectations of the intervention from the start. Some nurses described the impact of the GPs' negative attitude toward the study. One told of catching sight of her GP's face during a training session and realising that the doctor:
‘… wasn't that bothered about it, wasn't that interested in it. I remember her looking like “I can't be bothered to be here”, and maybe that influenced us.’
Even in practices where GPs endorsed the study in principle, the nurses said it was clear from the start that they never intended to be involved themselves. One said:
‘It was something for us to do.’
Desperation to help patients appeared to have affected the systematic recruitment of patients to the trial by practice staff: they grasped an opportunity to help patients for whom all else had failed. One GP stated that many of the patients put forward for the trial were the most difficult long-term cases, with very high BMIs, complicating health problems and difficulty exercising. In one practice the GP admitted that when she saw the list of patients who would be participating:
‘My heart sank. I thought, I don't think they'll get anywhere with these patients. I knew they wouldn't hear what was being said to them.’
Almost all the health professionals reported some degree of disappointment with the intervention. For some, this occurred during training, when they realised that the weight management model being offered was not radically different to the approaches they were familiar with. In the longer term, and in those practices that did seek to implement the model, disappointment in the study was more likely to come as a result of failure by the patients to lose weight or keep it off. A GP described her experience:
‘They were very keen to come and lose weight, but then it just slowly, slowly died down.’
Additional circumstances that may affect any long trial — staff changes, illness, and a practice split — were all cited as additional reasons for the poor implementation of the model.