Healthy You services to make lifestyle improvements and other interventions
Services available for all our patients to enable them to live better lives with support from specialist trainers/councillors
Several services have been created especially for our Eastern European patients.
Services are free and available to every patient registered with a GP Practice in Peterborough
All referrals available to our staff to refer using the Pink dot on the SystemOne toolbar – Clinical Support tools but we also have clinics provided by the Healthy You services at Thistlemoor Medical Centre.
Eastern European Health Trainer Clinics at Thistlemoor-pre-bookable
Eastern European Health Trainer clinics are available on Wednesday afternoons as face to face appointments.
You can book for Rasana Satiene’s screen (Healthy You) any patient who is +16years old who needs lifestyle support. This is for patients from Eastern European countries.
The first appt must to be booked for 1h, and follow up will be booked by Rasana for 30 minutes.
Jolanta Kristiene has her clinics on Tuesdays and Thursdays afternoons.
Any patient with Long term condition especially Diabetes and hypertension, heart failure, or newly diagnosed with hypertension, etc. who is overweight or needs support to make lifestyle changes-stop smoking, need dietary advise, need support for weight reduction, etc. can be referred to these Clinics.
Ana Madalina Damian (also speaks Romanian) is conducting clinics on Wednesdays afternoons at Thistlemoor. You can easily to refer patients as per instructions sent previously on Clarity. I am attaching document for your reference.
In terms of the referrals for Eastern European patients, please tick or write in narrative referral box ‘ Eastern European Health Trainer’, so this task is easily identified to go to appropriate person.
Patients may be referred to Healthy You for health checks.
Help is also available to quit Smoking. Please ask our staff to make the referral for you.
Adult Health Trainers
Up to 6 sessions of 1:1 support, across a whole year, from a Health Trainer who can help patients set realistic, health related goals. 60-minute initial assessment, 30 minutes thereafter.
This service can help with many elements of health such as; Healthy eating; Losing weight; Increasing physical activity; Reducing stress; Sexual health concerns.
16 + patients who want to make healthy lifestyle changes.
Tier 1 Physical Activity
Delivered by a consortium made up of the District and City Councils, Vivacity and Living Sport
Information and support to individuals who want to be more physically active, whether that be to lose weight, build strength or mobility, or improve their mental or social wellbeing.
Support for individuals and families to eat more healthily and maintain a balanced diet.
This is a universal service, suitable for all individuals and families who would like to become healthier across Cambridgeshire and Peterborough
Adult weight Management programme
12 week programme led by Nutritionists and Physical Activity Specialists – virtual and face to face offer. Each session lasts 60-90 minutes.
Healthy eating advice and discussions followed by an exercise-based activity session.
Support with setting achievable goals to help patient with positive lifestyle changes and sustainable weight loss.
Or a 12-week referral to Slimming World or Wellness that Works (formerly Weight Watchers)
anyone 16+ with a BMI equal or greater than 25
Tier 3 Weight Management
Delivered by Everyone Health in partnership with Cambridgeshire University Hospitals and Oviva, across Cambridgeshire and Peterborough.
Aged 18+. Must have engaged with tier-2 weight loss intervention within the two years prior to referral to tier-3 but has not been able to achieve/maintain weight loss
BMI 30 Kg/m2 if the patient has complex needs and had not responded to previous tier interventions,
BMI 35Kg/m2 with type 2 diabetes or BMI 40Kg/m2 • Reduce the above criteria by BMI 2.5Kg/m2 if Asian origin
Falls Prevention FaME
Weekly group exercise classes designed to improve the patient’s physical fitness, strength and balance.
The exercises within the class are progressed slowly according to ability and the exercises are specifically developed to help patients feel steadier on their feet and to improve confidence.
A falls assessment will be completed prior to exercise
Patients aged 65 or over; History of falls (injurious or non-injurious);
Fear of falling;
Low bone density and/or family fracture;
Medically Stable with any conditions under control;
Use of a walking Aid
A 12-week programme – virtual and face to face offer
Advice from Stop Smoking practitioner who creates an individually tailored plan for every patient.
Guidance on choosing suitable medication and information on how to manage cravings and withdrawal symptoms provided.
The Healthy You Stop Smoking Service is available for anyone from the age of 12 and upwards.
For young people under the age of 13, parental consent, however, will be required in order to access this service
NHS Health Checks
An NHS Health Check records the patient’s height, weight, age, sex, ethnicity, blood pressure, cholesterol and HbA1c levels. Immediate results are shared with the patient’s GP.
20-30 minutes appointments available during the day, weekend and evenings.
Advice on how patient can improve their health and help to get specialist support if needed.
Residents aged between 40 – 74 years who haven’t had a NHS Health Check in the last 5 years
Specialist Health Trainers
Mental Health Trainers What: Up to 8 sessions of 1:1 healthy lifestyle support for patients diagnosed with a mental health illness. Our Health Trainers can help the patient with many elements of their health such as – Healthy eating; – Losing weight; – Increasing physical activity; – Reducing stress; Growing a network of support; Creating more structure to their day. 60-minute Initial assessment, 45 minutes thereafter.
Eastern European Health Trainers Fenland and Peterborough What: Up to 6 sessions of 1:1 healthy lifestyle support, in the patient’s national language (will engage with translator services if the Health Trainers do not speak their language), which can help the patient with many elements of health such as: – Healthy eating; – Losing weight; – Increasing physical activity; – Reducing stress; Reducing alcohol consumption. 60-minute Initial assessment, 30 minutes thereafter.
Alcohol Health Trainers What: The patient can meet an Alcohol Health Trainer for up to 8 1:1 sessions for support in reducing their alcohol consumption. They can also look at other areas of behaviour change, including; – Healthy eating; – Losing weight; – Increasing physical activity; – Reducing stress. 60-minute initial assessment, 30 minutes thereafter.
Carer Health Trainers Cambridgeshire What: For all adult carers who are looking after someone with long term illness or dementia. Up to 6 sessions of 1:1 healthy lifestyle support, supporting the patient with many elements of health such as; – Healthy eating; – Losing weight; – Increasing physical activity; – Reducing stress
Social Prescribers referrals
Gina Goubarn and Shamina Ladak
To refer the patient to Social Prescribing Service, you need to click on pink box (Neighbourhood Community Referrals). Choose one of the option – Social Prescribing and Health Coaches. Find Thistlemoor & Central PCN with Gina’s name.
When you refer the patient by using the Social Prescribing template above, please also book the patient on the Social Prescriber’s weekly screen ( to process for all week) which is set up each Saturday.
This helps us to check how long the patient might wait for the contact from the service.
Very Low Calorie Diet VCLD
Patient Eligibility and Exclusion Criteria
Patients < 65 years
BMI 27-45 kg/m2
With T2DM < 6 years
Current insulin use
Weight loss of >5 kg within the last 6 months
Recent eGFR <30 mls/min/1.73 m2
Myocardial infarction within previous 6 months
Severe heart failure defined as equivalent to the New
York Heart Association grade 3 (NYHA)
Current treatment with anti-obesity drugs
Diagnosed eating disorder or purging
Pregnant/ considering pregnancy
Patients who have required hospitalisation for depression or are on antipsychotic drugs
Agnieszka has already sent the information to all the eligible patients- however, it is always best to discuss the option with patients who may be eligible and we will be able to recruit more patients.
This programme is suitable for all eligible patients with hypertension, diabetes who are interested in reversing their diabetes.
If you are unsure which patients are eligible, please send a task to Agnieszka for confirmation.
Also, if you find an eligible patient, please send her a task to refer the patient.
The NHS Digital Weight Management Programme
Information for healthcare professionals
Currently, general practices and community pharmacies can refer members of the public to the NHS Digital Weight Management Programme.
About the programme
The programme offers online access to weight management services to people living with obesity who also have a diagnosis of either diabetes, hypertension, or both.
With three levels of support and a choice of providers, it is designed to offer service users a personalised level of support to help them manage their weight and improve longer term health outcomes.
Who can be referred?
Referrals to the programme are only for people that meet the following criteria:
are over the age of 18
have a body mass index (BMI) of 30 or more (adjusted to ≥27.5 for people from black, Asian and ethnic minority backgrounds)
have a diagnosis of diabetes (type 1 or type 2), hypertension or both.
Who cannot be referred?
Any person that meets any of the following exclusion criteria should not be referred to the programme:
recorded as having moderate or severe frailty
has an active eating disorder
has had bariatric surgery in the last two years
people for whom a weight management programme is considered to pose greater risk of harm than benefit.
For people aged over 80 years old, the referrer will need to confirm on the referral form that a weight management programme is considered likely to pose greater benefit than harm.
How the programme supports the NHS Long Term Plan
The NHS Digital Weight Management Programme supports the delivery of the NHS Long Term Plan commitments relating to obesity, focusing on weight management to support people living with obesity who also have a diagnosis of diabetes, hypertension or both. Obesity is a serious health concern that increases the risks of many other health conditions, including Type 2 diabetes, cardiovascular disease, joint problems, mental health problems and some cancers.
There is also evidence to suggest that people living with obesity are more likely to be admitted to hospital, intensive care and, sadly, die from COVID-19 compared to people living with a healthy body weight.
The NHS Digital Weight Management Programme provides weight management services flexibly, without the need for people to travel.
Evidence from the NHS Digital Diabetes Prevention Programme shows that digital and remote weight management services are more likely to be accessed by younger (working age) people whilst maintaining comparable results to face-to-face weight management services.
The programme has been designed to offer service users a personalised level of intervention to support them manage their weight, improve quality of life and improve longer term health outcomes. It works alongside and does not replace existing weight management services funded by local authorities.
Weight management services can provide substantial health benefits to people and can benefit the NHS by preventing future diseases, and the NHS Digital Weight Management Programme means weight management services are accessible to more people.
Referrals to Digital weight management programme from SystemOne
To continue making referrals and to save time by ensuring more of the patient’s information auto-populates you should now use the referral form available on S1- ‘MLCSU Weight Management ES NHSEI V2’
When referring patients, please always add read code for the referral: Referral to weight management service (Y2e63).
Information for patients
How to access the programme
The NHS Digital Weight Management Programme could help you if you are living with obesity and also have diabetes, high blood pressure, or both. If this is you, you could benefit from this 12-week programme. It’s free and easily available via a smartphone, tablet, or computer.
How to start the programme
To start your journey to a healthier lifestyle, you need to speak to your GP
You can read more about the programme in our leaflet.
Who can be referred to the programme?
You must be 18 or over.
You must have a BMI greater than 30. The BMI threshold will be lowered to 27.5 for people from black, Asian, and ethnic minority backgrounds, as we know people from these ethnic backgrounds are at an increased risk of conditions such as Type 2 diabetes at a lower BMI.
You must have diabetes, high blood pressure, or both.
You must have a smartphone, tablet, or computer with internet access.
If you do not have diabetes or high blood pressure, you may still benefit from the NHS Better Health programme.