TRANSFORMING PRIMARY CARE: ADDRESSING LIFESTYLE-RELATED HEALTH ISSUES THROUGH LIFESTYLE CLINICS

In response to the growing burden of non-communicable diseases and lifestyle-related health issues, Leamington North and South Primary Care Networks (PCNs) implemented a series of lifestyle clinics designed to support behaviour change in patients. These clinics focus on education, community support, and holistic health improvements, particularly targeting those with high clinical and social needs. The project integrates a multi-disciplinary approach, bringing together health coaches, dieticians, and social prescribers to create personalised, sustainable health interventions.

Why change was needed 

Primary care in the UK faces huge challenges, including rising workloads, limited resources, and increasing prevalence of lifestyle-related conditions, such as obesity, hypertension, and diabetes. The current healthcare system often focuses on managing the complications of these diseases rather than preventing them. With an aging population and an obesogenic environment, there is a growing need for more effective preventative healthcare approaches.

In Leamington, a large proportion of the population is impacted by social determinants of health, including poverty, poor access to healthy food, and limited opportunities for physical activity. The rising rates of obesity, with 68.6% of men and 59% of women classified as overweight or obese, are a clear indicator of the need for intervention. This is amplified by lifestyle factors such as sedentary behaviour and unhealthy eating habits, which are influenced by urbanisation and the availability of processed foods.

The introduction of Primary Care Networks (PCNs) in 2019 presented an opportunity to rethink primary care delivery. PCNs provide a platform for more integrated services, with the potential to deliver tailored, community-based health programs. A key aspect of these networks is the incorporation of multi-disciplinary teams, which includes social prescribers, health coaches, dieticians, and pharmacists. This enables a more holistic approach to patient care, particularly for those with chronic conditions linked to lifestyle factors.

What we did 

In response to these challenges, Leamington North and South PCNs launched a Lifestyle Clinic initiative aimed at addressing the rising tide of lifestyle-related health issues. The program was designed to focus on behaviour change, community support, and patient empowerment.

The initiative incorporate a four-session group clinic model, with each session addressing different aspects of health and wellness:

• Session 1: Happy, Healthy Me – Led by a GP and health and wellbeing coach, this session aimed to build trust and identify patient motivations for change, while providing a framework for setting personal goals.
• Session 2: Behaviour, Community, and Hurdles – Led by a social prescriber, this session focused on understanding the factors influencing behaviour and introduced tools for tracking progress, including a mobile application.
• Session 3: Nutrition, Not Diet! – Led by a dietician, this session helped patients understand the importance of balanced nutrition, while also debunking myths about food and its impact on health.
• Session 4: Physical Activity – Led by a health and wellbeing coach, this session emphasised the role of physical activity in overall health and encouraged patients to embrace movement in enjoyable ways.

Patients were identified through multiple referral pathways, including self-referral, clinician referral, social prescribing, and population searches, allowing for targeted interventions based on clinical and social need. The program incorporated community engagement by collaborating with local events like parkrun, providing patients with opportunities for social support and physical activity.

The Lifestyle Clinics showed significant positive impacts across multiple areas, particularly in physical activity levels, readiness to change, mental wellbeing, and lifestyle behaviours. Key findings include:

Key findings:

Increased physical activity

• Participants showed a significant increase in physical activity after attending the lifestyle clinics.
• However, for some, activity levels started to decline one month after the program ended, indicating the need for sustained support.

Improved readiness to change

• Participants demonstrated greater readiness to adopt healthier habits, suggesting a shift in mindset towards long-term behaviour change.

Better health outcomes (especially for females)

• Female participants reported improved health status, particularly in terms of mobility and pain reduction.
• Male participants showed more sustained increases in physical activity levels.

Mental wellbeing improvements

• Short-term gains were observed in mental wellbeing, but for some, these benefits faded over time.
• Anxiety and depression levels improved post-clinic but showed some regression at the one-month follow-up.

Improved knowledge of health and nutrition

• Patients gained better understanding of the benefits of physical activity, diet, and sedentary behaviour.
• There were positive changes in eating habits, including increased fruit and vegetable intake and greater portion control.

Behavioural changes in lifestyle factors

• Alcohol consumption decreased significantly post-clinic and remained lower at follow-up.
• Smoking was very low among participants, so no significant changes were observed.
• Fast food and sugary drink consumption decreased, but some participants returned to previous habits over time.

What’s next? 

The PCN plans to expand these lifestyle clinics further, integrating more community-driven health programs and strengthening partnerships with local organisations. The focus will remain on prevention and early intervention, with the goal of improving patient outcomes and addressing social determinants of health. Additionally, efforts will continue to enhance staff engagement and wellbeing through the evolving multi-disciplinary model.