Developing a long‐term follow up service for bariatric surgical patients in the community: Patient and professional perspectives

Abstract Background In the UK, bariatric surgical patients are followed up for 2 years post‐operatively in hospital settings, before being discharged into General Practice for long‐term follow‐up. Presently, there is ambiguous guidance as to what should be included in a community‐based bariatric surgical follow‐up service. The aim of the study was to understand, from both patient and professional perspectives, what is needed to support the long‐term management of bariatric surgical patients in community‐based settings. Methods Post‐surgical bariatric patients and General Practice staff were recruited from an area in the UK which has an National Health Service (NHS) hospital providing a high‐volume and established bariatric surgical service. Data was collected through semi‐structured interviews. A thematic analytic framework was used to construct eight themes which illuminated the participants' experiences. The study took place between March and December 2021. Findings Thirty participants (14 patients and 16 healthcare professionals) were recruited to the study. The study revealed the lack of a framework for delivery of a long‐term follow up service was frustrating to both patients and professionals. Patient participants reported needing more support, especially dietetic and psychological input, and professionals stated they had little knowledge about bariatric surgical care, and what was needed to provide optimal care, but wanted to provide quality patient care. Conclusion Long‐term follow up of bariatric surgical patients is an important issue which needs addressing. This study illuminates both the patient and professional perspectives on developing a pragmatic, community‐based service which meets the needs of patients and considers the need to incorporate such a service into existing infrastructures without adding additional demands on General Practice.


| INTRODUCTION
In the UK, patients who undergo bariatric surgery are followed up for 2 years in Secondary Care before being discharged into General Practice for long-term follow up. General Practice, sometimes referred as Primary Care or Family Medicine, is defined as a range of non-acute services provided in community settings such as doctors' offices and community pharmacy offering patient care. Guidance as to what should be provided in a community-based follow up service gives an overview of the areas to be covered, 1 guidance on nutritional requirement, 2, 3 and suggestions for managing bariatric patients in the community 4 have been published, but there is no formal consensus, detailed protocol or which healthcare professionals should be included in this type of follow-up service and what it should entail.
The knowledge levels of bariatric surgical care amongst many General Practice staff are currently unknown, with research from patients suggesting this may be low. 5 The bariatric surgical unit at Sunderland Royal Hospital is one of the busiest units in the UK, and it follows that there are a correspondingly high number of bariatric surgical patients living within Sunderland who require long-term support and monitoring in community settings.
With current high demands on General Practice in the UK, 6 the logistics of developing a pragmatic, viable framework to embed and sustain a long term follow up service for the monitoring and support of people living with bariatric surgery need to be scoped and established.
Studies have shown that Community Pharmacists, who have diverse roles in General Practice, possess specialist expertise and knowledge, for example, pharmacokinetics, which are important to bariatric surgical care, as the effects of many medications and supplements are altered after bariatric surgery, given the malabsorptive and restrictive elements of procedures. [7][8][9] Nearly 90% of the UK population has a community pharmacy accessible in a 20 min walk, 10 community pharmacies have longer opening hours than other healthcare providers, do not require an appointment, and 90% have private consulting rooms. 11 Pharmacists are also working more closely with General Practice as part of the UK National Health Service's (NHS) Long Term Plan 12 to develop and deliver local services based on patient needs. 13 The role of Community Pharmacy may have potential to contribute to supporting follow-up care for people who have undergone bariatric surgery, but like other General Practice professionals, the roles are currently not articulated. Any community-based bariatric follow-up service needs to be developed with the voices of both services users as well as healthcare professionals, ensuring that the service would be pragmatic to deliver and meet the needs of patients. Studies carried out from the patient perspective in bariatric surgical care 5,7 have been helpful in providing insight into care and influencing healthcare decision-making.
The aim of the study was to understand, from both patient and professional perspectives, what is needed to support the long-term management of bariatric surgical patients in General Practice settings.

| MATERIALS AND METHODS
A qualitative methodological framework underpinned the study.
Qualitative methods are useful when trying to understand peoples' thoughts, experiences and feelings toward the subject under investigation. 14 Data from participants is often collected in their "natural environment" for example, a surgery for a general practitioner (GP), and a domestic or other setting for a patient, in order that the participant feels comfortable taking part in the study. 15 Two cohorts of participants were recruited to the study using clear inclusion and exclusion criteria (see Table 1). Firstly, patients who had undergone bariatric surgery at Sunderland Royal Hospital were identified from clinic lists and approached in writing with study information including a letter of invitation, a participant information sheet, a consent form, and a reply-paid envelope. All participants were informed they could contact Yitka Graham if they had any queries before making their minds up about whether to take part or not. Owing to the geographical specificity of the bariatric surgical service, and local General Practice settings who serve most patients who underwent bariatric surgery there, the inclusion criteria was limited to meet the aims of the study.

Inclusion criteria
Exclusion criteria

Healthcare professionals
Staff working in General Practice within the city of Sunderland (full and parttime) Staff working in General Practice outside the city of Sunderland Ability to provide consent Staff who were retired, off sick, or unable to provide consent

Patients
People who have undergone bariatric surgery procedures (Roux-n-Y gastric bypass, one anastomosis gastric bypass, sleeve gastrectomy) People who are on waiting lists or have not undergone bariatric procedures Primary or revisional bariatric procedure People living outside Sunderland People living in the city of Sunderland Inability to provide informed consent Ability to provide informed consent GRAHAM ET AL.
Healthcare professionals working in General Practice across Sunderland were identified by a register of GP practices and approached in writing. Potential participants who wanted to discuss the study further, along with those who wished to take part contacted Yitka Graham, who answered any questions and for those who wished to take part, took informed consent prior to data being collected.
Data was collected through individual, interviews with participants (using video-conferencing to adhere to social distancing guidelines), using a topic guide (see Figures 1 and 2) to facilitate discussion. 14 Interviews were audio recorded, anonymized and transcribed verbatim by an approved transcription company. A £10 Amazon® voucher was offered to all participants.

F I G U R E 1
Topic guide for patient participants.
F I G U R E 2 Topic guide for healthcare professional participants.
Data were analyzed through a data thematic analytic framework, informed by the methods of Braun and Clarke 16 and Robson. 17 Thematic analysis is a qualitative methodology which allows patterns or themes to be constructed from collected data, with themes allowing exploration of the parts of the situation, allowing a greater understanding of the whole. 18 The patterns, or themes constructed from the data present an interpretation of the situation under investigation, with the thematic analysis informing recommendations and scope for further research. Transcripts were read by the research team to familiarize themselves with the data, followed by each person identifying codes, or areas that were felt to be relevant to answering the research question. These were then discussed amongst the team, with an initial set of themes produced.
These themes were discussed and further refined, with a consensus reached on the final eight themes. The data analysis was enhanced by a social constructivist perspective, which asserts that reality is shaped through interactions with others and influenced by life experiences, social norms and values. 19 Using this perspective helped to understand the perceptions of the social constructs of roles of patient and professionals which would assist to further illuminate findings.
This study received favorable ethical approval from the UK

Health Research Authority and the University of Sunderland
Research Ethics Group.

| RESULTS
There were 30 participants recruited to the study, comprising patients (n = 14) (see Table 2) and healthcare professionals (n = 16) (see Table 3). Recruitment took place from July to October 2021. There were eight themes constructed from the data, four with patient participants and four with healthcare professionals. Of the 14 patient participants, 11 were female (78%) and 3 were male (22%

| Theme 3 (patients) needing a multidisciplinary approach to support and care
Patient participants reported needing a biopsychosocial approach to long-term follow-up, being able to draw upon the support of a range of expertise from clinicians: Psychology and mental health:

| Theme 4 (patients) coping with the pandemic in the context of living with a bariatric-surgically altered body
Analysis found that the pandemic had an acknowledged impact on people living with a bariatric-surgically altered body, which needs to be taken into consideration as the temporality of the pandemic is as

| Theme 6 (professionals) acknowledging the lack of a formal process for managing post-bariatric surgical patients in General Practice and community healthcare settings at present
There is no protocol as such. We get a letter from the hospital highlighting what they are expecting the practice to follow up on and to do. Starting supplements, things like that, but no protocols as such. If a patient contacts us and says 'I have had surgery on such and such a date and I was told to contact, you with regards to this'. We would bring them in every twelve weeks for B12 injections and things like that, and also to monitor other ongoing health issues such as hypertension, we'd be reviewing them for that anyway, but no specific bariatric protocol'.

| Theme 7 (professionals) identifying patientreported issues and managing expectations
Healthcare professionals felt that many patients needed to understand that there was more to bariatric surgery than just weight loss, and expectations following surgery needed to be managed: They [patients] think their life is going to be complete when they lose weight, but actually, that's just one part of it…that you've still got to make an effort to be fit.
Losing weight doesn't mean you're fit and it doesn't mean you're happy. And I think there is that expectation that once they lost the weight, their life will be complete and everything will be fine….it takes a couple of years down the line for them to realise that is not necessarily the case.

| Theme 8 (professionals) considering how patients could be supported in the community
The expertise of other healthcare professionals could be utilized to support GPs: Pharmacists are in a good position to support. When we do the structured medication review we take a more holistic approach, we explore their lifestyles, BMI etc…we explore mood, sleep, bowels and what they've been swallowing…I have referred a few bariatric patients for social prescribing. Both patient and healthcare professionals reported that the lack of a formal long-term follow up service for bariatric patients was frustrating and difficult in terms of optimal support and care. Common to both cohorts of participants was the identified need for a multidisciplinary approach to long-term follow up, with a particular emphasis on identifying and supporting mental health needs. Of particular interest was that many of the healthcare professionals were unaware of how many bariatric patients they had in their practice and how often they presented. The variance in response suggests this information is not readily available, which we argue is needed to understand not only the number of patients, but why they are presenting and what their needs are.
The healthcare professionals who took part in this study reported low levels of knowledge about bariatric surgical procedures and optimal care of post-bariatric patients. Literature shows this is a common phenomenon in General Practice. 21,22 The patient participants in this study felt that healthcare professionals did not understand what patients wanted and needed after surgery, this has also been identified in studies. 23 Patient participants did not blame individual healthcare professionals for this, our study showed that this was interpreted as a wider, systems issue.
There was a paucity of published studies examining patient and healthcare professionals' experiences of utilizing and providing bariatric patient support in General Practice settings. Literature has shown that the lack of formal guidance for long-term follow up of bariatric patients is resulting in patients not being able to either access or receive optimal care. As study of over 3000 patients in the UK found that patients were not receiving the recommended nutritional monitoring in the community. 24 A retrospective analysis of 385 patients found that patients who attended follow-up clinics were more likely to have better excess weight loss and total weight loss than those who did not access follow up services. 25 A study on post-surgical outcomes with 169 sleeve gastrectomy (second most commonly performed procedure in the UK) found that after 5 years, only half the patients had achieved more than 50% of their excess weight loss, with physical activity, eating patterns, and eating pathologies influencing weight outcomes, 26 clearly supporting the need for dietitian support as found in this study. The need for psychological support as part of long-term follow-up was identified by both patients and healthcare professionals.
The patient transition from Secondary Care to General Practice and community care after 2 years may be better supported with a coordinated approach, where General Practice is involved during the handover, so follow-up is coordinated in collaboration with the bariatric multidisciplinary team, for example, surgeons, the dietitian and mental health professionals. 27 It is noted that the multidisciplinary team approach to bariatric care is an established concept in Sec-  32 reflects the findings of the patient cohort of our study.
Studies have found that post-operative bariatric care and patient compliance has been adversely affected by the pandemic. 33,34 The data for this study was collected in 2021, a year into the pandemic, which means that any potential impact of COVID-19 for example, social distancing measures and other impact on post-surgical bariatric patient care was captured, and incorporated into recommendations for future planning of service provision. Many healthcare professionals reported seeing fewer bariatric surgical patients since the start of the pandemic.
The limitations of this work are that it was undertaken in a specific area of the UK, and the population demographics and community healthcare provision may be different in other areas of the UK and in other countries. There were also a high number of White participants in our study, but this is reflective of the local population demographics. We had more female patient participants than male in the study, but it is evidenced that more females than males undergo bariatric procedures 35 The strengths of this study were that both patients and healthcare professionals were represented, so comparisons could be made to offer a balanced perspective to inform rec-