Evidence
In this video, a narrator explains the background and results of the study, and animations are used to illustrate the narrative. The narrative is included below, along with any text displayed on the screen.

[Narrator] Guidelines say we should be opportunistically intervening on our patient's weight. You will achieve the best outcome for your patients if you offer them a free referral to a weight management service.

Evidence shows that commercial services, like slimming world and weight watchers are more effective than trying to lose weight without support, and are not only cost-effective but cost-saving even if people put the weight back on.

In many areas these are available on the NHS, although no weight management service or other services might be available where you work.

We've analyzed hundreds of recorded consultations between GPs and patients, where the GP opportunistically offers referral to commercial weight management services, like Slimming World or Weight Watchers.

We found these conversations can easily fit at the end of a typical consultation, and that if you are positive about them your patient is likely to be too.

We identified what you can say that is likely to be well received by your patients, and is also likely to lead to attendance at weight management services. We've found you can have positive helpful conversations in around 30 seconds.

Offering a referral doesn't need to be complicated. Simply,

[Text on screen] Raise the topic, Establish services are effective, Offer a free referral, Acknowledge the patient’s response, Outline next actions.

Let's look at an example:

“The evidence about the best way to lose weight shows that commercially run weight management organizations like Weight Watchers have the best results. I can actually offer you the opportunity for a free referral to a local one today for 12 weeks. Would you be interested in going along to one of those?”

“Yes, I would”

“Brilliant! I would really encourage that. I can make a referral today, and you'll get a call from the weight management service soon.”

Here are some techniques you can use at each of these stages, that will support you to have effective, brief and well-received conversations.

Conversation toolkit

1. Raising the topic
It may feel strange to raise the topic out of the blue, but it's easier than you might imagine.
“While you're here can I check your weight please?”
When stating the patient's weight don't say obese or BMI but mention that their weight is higher than you would like it to be, and immediately mention that some support is available.
“Your weight is a little bit higher than we'd like, and I can actually offer you some support to lose weight today”

2. Established Commercial Weight Management services are effective
Before offering a referral, it's important to first say that commercial weight management services like Weight Watchers or like Slimming World are the best way to lose weight.
“Did you know that commercial weight management services like Slimming World are the best way to lose weight? People do really well with that, they're far more successful than trying on your own.”
If you don't do this patients are unlikely to agree, as they may not know they are effective.

3. Offer a free referral
There are five important features of the referral, which should be simple, short and jargon free:
Be confident
Confidence is key. Remember you're offering something that normally costs a lot of money for free.
We found no evidence that patients are upset or offended by this, but if you sound reluctant or nervous they are unlikely to want to attend.
Don't talk about other conditions
It may seem like a good idea to talk about the benefits of weight loss for a patient's existing condition, like diabetes or asthma [infertility, heart disease, high blood pressure, joint pain].
However, our research has shown that this is one thing that can make patients upset or defensive. So this strategy is best avoided.
Offer an opportunity
Simply say, “I can offer you the opportunity of a free 12-week referral at a service like Weight Watchers or Slimming World, these are local and will support you to lose weight”.
Our research has shown that saying the words offer, opportunity, support and local are well received, and address questions patients may otherwise ask later.
Saying the word free is very important.
[Text on screen] Would you be interested in that?
Would you be interested
After you've outlined the offer, ask the patient directly “Would you be interested in that?”
The way you make the offer is important, don't use if or or as this is likely to open discussion further and take a longer time.

4. Acknowledge the patient's response
Here's how to reply to patients in ways which are likely to keep the conversation brief and motivational. Remember, it is very unlikely your patient will be upset or offended by these conversations.
Your patient may say they're already losing weight, acknowledge and congratulate these current or past efforts. If they're already losing weight they can still attend a weight management service, and this could be really helpful to support them to keep up the good work.
“That's brilliant!”
If patients are unsure or on the off chance they're upset, saying “I think this will be a really good thing” can support them in making their decision. It's unusual to be offered these referrals at the doctors and patients may be unsure about accepting, but knowing that their doctor thought this was good and helpful, really supports patients in making their decisions.
Surprisingly we found that when a patient said “Yes?” or “Yeah?” in response to an offer they weren't always agreeing, they were actually requesting more information. If your patient says “Yes?” or “Yeah?” try telling them a little more about what you're offering.
However, our research showed that a positive response like “Yes definitely!” or “That sounds good” indicated enthusiastic receipt of the offer. If your patient responds this way, be positive too and move to the next steps.
Listen for the word “Oh!” this shows an offer is well received, and you can stop persuading and move to make the referral right away.
“I can actually refer you for free today.”
“Oh right!”
Some people don't want to accept the referral, and trying to convince or persuade people that had declined an offer doesn't work, and is likely to make people frustrated, and could sound like you aren't listening to them.
If your patient does say no, acknowledge their decision but remind them you're there to talk if they ever want to discuss their weight again.
“Would you be interested in doing something like that?”
“No, not really. No.”
“Okay that's fair enough. Please do come back if you want to talk more about it.”

5. Next steps
It may seem obvious that a person who's motivated enough to lose weight, is also motivated enough to make their own appointment. But that's simply wrong. Clinical trials show the reverse.
Simply taking the onus of initial contact out of the patient's hands and leaving it in your hands, as would be true of all other referrals you make, is the single most important thing you can do to facilitate engagement with the weight loss program and encourage long-term weight loss. And ask them to come back in a month to see how they're getting on.

Remember, even if you don't follow all of our advice, it's very unlikely you will cause offence as long as you sound positive, confident and respect the patient's decision. By offering a referral, you are offering your patient the best opportunity for a supportive and effective way to lose weight.

If you have more questions, check out the Public Health England guidelines available on the gov.uk website: Let's talk about weight.
Visit https://doi.org/10.1093/fampra/cmaa121 for the full research study.

[Text on screen] Let’s talk about weight gov.co.uk
Get in touch with your local authority Public Health team for information on free weight management services available in your area.

Logo: Nuffield Department of Primary Care Health Sciences, University of Oxford

Specific phrases about weight management programmes help GPs make successful referrals

Specific words and phrases help GPs make successful referrals to weight management programmes in brief consultations. Research found that people who are overweight are more likely to accept a referral when GPs describe a ‘programme’ or ‘service’ – rather than a ‘club’ or ‘group’. Stating early on that the programme is both free of charge and local is important; mentioning well-known brands such as Slimming World also helps explain what it is.

GPs may be reluctant to start these conversations, partly through concern about the time they can take. The research found that making a series of clear points avoided lengthy discussions. Lack of clarity in a consultation can leave people who wish to lose weight confused and can derail conversations about the help on offer. 

In this study, researchers explored details of GP consultations about weight management programmes. They wanted to identify the elements of conversations that prompt smooth progress to a referral, and those that result in confusion or misunderstanding. 

They conclude that when GPs use certain key phrases, more people are inclined to attend weight management programmes. 

What’s the issue?

In England, GPs are encouraged to refer people living with obesity to 12-week weight management programmes. The programmes offer behavioural support to follow a weight-reducing diet and increase physical activity. Free attendance is already available in some areas, and is being rolled out nationally as part of NHS England’s new plan for tackling obesity. 

Previous research by the same group studied people who had a routine GP appointment for a reason unrelated to their obesity. GPs were asked to offer a weight management programme to everyone eligible; three in four (77%) accepted the GP’s offer of referral. Two in five (40%) attended and, after a year, they had lost 5kg on average. But almost one in four turned down the GP’s offer.

In addition, other evidence suggests that GPs rarely offer referral, especially when weight is irrelevant to the reason for the consultation.

Researchers wanted to find the best way to maximise the numbers of people accepting a referral. They looked in detail at conversations GPs had with patients, to work out what helps smooth the path to referral. They asked whether variations in the conversation could explain variations in acceptance. 

What’s new?

The researchers analysed 246 consultations in which GPs offered referrals to commercial weight management services or programmes. The recordings were of 77 GPs in 37 practices. They ranged in length from 8 to 458 seconds; the average was 95 seconds.

There were no examples of people getting upset at the offer. Most seemed happy to discuss their weight and how it could be managed. 

However, the researchers found key aspects which could smooth the discussion and increase the likelihood of a patient accepting a referral:

    • Using brand names such as Slimming World helped people understand quickly what a ‘commercial weight management programme’ is. GPs did not always explain the term, and patients often did not know. 
    • Describing a ‘service’ or ‘programme’ increased people’s interest. Some were resistant to joining a ‘club’ or ‘group’ which sounds informal and social, as opposed to a structured service.
    • Making clear that the programme is free for all 12 sessions, and not just the initial referral, was essential. This point needed to be made early on, otherwise concerns about cost could derail the conversation. 
    • Making clear that the programme is local made people more receptive. 

GPs who made these points early on were able to avoid lengthy discussions to clear up misunderstandings about location, for example. They were able to move on quickly to ask if a patient wanted to attend. 

Why is this important?

Most people in the UK attend their GP at least once a year. If all those with obesity or overweight were offered a referral to a weight management programme, the numbers of people who are overweight would be reduced. The researchers' previous work calculated it could reduce levels of heart disease in the population by 22% over 10 years

The researchers say that the conversation can take place in around 30 seconds. There is currently general advice, but no guidelines to lead GPs through these consultations. This research shows that using specific words and phrases – and giving key information early – can smooth the conversation and improve patients’ understanding of what is on offer. It may help GPs to feel comfortable making the offer and increase the numbers of patients willing to accept it. 

What’s next?

The researchers have produced a short video for clinicians. It explains how to make a brief offer of support with weight loss, and a referral to weight loss services, in the way most likely to succeed. 

The team encourages all primary care staff to become familiar with the key points to make. It will help them refer people to free weight loss programmes in their area, when they are available. 

You may be interested to read

The full paper: Albury C, and others. Discussing weight loss opportunistically and effectively in family practice: a qualitative study of clinical interactions using conversation analysis in UK family practice. Family Practice 2020;cmaa121. 

A clinician training video based on this paper (featured here)

Further guidance on weight management referrals from the authors and Public Health England.  

The trial carried out by this research group looking at the effectiveness and acceptability of offering weight management programmes: Aveyard P, and others. Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial. Lancet 2016;388:10059. 

 

Funding: This research was funded by the NIHR School for Primary Care Research and a Mildred Blaxter Fellowship from the Foundation for the Sociology of Health and Illness.

Conflicts of Interest: Slimming World and Rosemary Conley donated free weight management courses for NHS patients enrolled in this trial

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

We know from our previous research that if every GP in the country delivered these offers, it could lead to population-level weight loss. That’s any GP doing it in any way, and it’s great. But by analysing real consultations we were able to identify the best way to communicate in these discussions. If GPs followed this optimised approach, it is likely that population level weight loss could be greater; they would be delivering the offer in a clear way that avoids the misunderstandings that can lead to refusal. The benefit of this study is that a forensic sequential analysis of real conversations (rather than asking people what they remember after-the-fact) enabled us to identify specific words and phrases that are received well, and promote smooth discussions.

GPs report in studies that they are concerned people might respond in a negative way to discussions about weight, but we just didn’t see that. In over 200 examples, no patient became upset. Most really wanted to talk to their GP when the chance came up. 

It’s important to avoid misunderstandings that could lead to confusion or even damage the doctor-patient relationship, and we found some ways of talking could do this. The information we present helps to avoid these misunderstandings, ensure discussions are patient-centred, and allow people to make informed decisions, based on the key information. If some information is missing – for example if people think they are being asked to pay – things can become awkward. But it can be straightforward: ‘This is an offer, it’s free to attend, it’s your choice to accept or decline, but here is the information that can help you decide’. 

Charlotte Albury, Mildred Blaxter Research Fellow, Nuffield Department of Primary Care Health Sciences, University of Oxford. 

Diabetes UK 

We know that the language used and having timely conversations are key to encouraging uptake to weight management services, where they are available. Healthcare professionals should use appropriate, non-stigmatising language to inform people of the services available to them.

Nikki Joule, Policy Manager, Diabetes UK 

Lived experience 

I live with obesity and have not had a conversation like this with my GP. The research might help GPs approach conversations with patients about weight management services, and open up the possibility of discussion. Weight loss programmes may help in short-term weight loss, but for me, and for others I have talked with, it is important for GPs to offer long-term psychological support.  GPs need more time with patients for these conversations to take place and to allow them to get to the heart of the issues.

Deb Smith, Champion for Obesity Empowerment Network 

Researcher 

Albury et al. provide important findings about how clinicians might make effective referrals for weight loss programmes in primary care. Discussions about weight or weight management, alongside other forms of ‘lifestyle advice’, can be difficult for patients, in terms of help-seeking, and clinicians, in terms of knowing how to provide advice in ways that are tailored to patient needs, reassuring and which encourage uptake to the advice after the consultation.

The authors used conversation analytic methods to transcribe and analyse a large number of recorded primary care consultations. The use of empirical data, rather than simulated interactions or self-reported methods, means that the findings are grounded in what works well for patients and clinicians in terms of promoting shared understandings about the importance of weight management and minimising ‘resistance’ (i.e. disagreement) to the advice. The 5 components to effective referrals described are also relatively simple to understand and remember, and could therefore be easily adapted by clinicians to use within their consultations.

The overall paper is an important contribution to literature about advice-giving in primary care and an excellent example of how findings from communication research can be used to inform policy and practice.” 

Catherine J. Woods, Research Fellow, University of Southampton