Lot 3 Service Specification
Tier 3 Adult Weight Management Service Specification
Document revision control
Version
1
2.
3.
Author/editor
Dawn Lockley
Dawn Lockley
Dawn Lockley
Notes
Draft
Final Draft
Final
Date
23/12/2013
16/04/2014
10/07/2014
1: Introduction
1.1 This commissioned service will help to deliver health improvement and Public Health
outcomes for the Public Health Outcome Framework indicators as follows:
2.13 Proportion of physically active and inactive adults.
2.13 (i) % of adults achieving at least 150 minutes of physical activity per week in accordance
with UK CMO recommended guidelines on physical activity.
2.12 Excess weight in adults (% overweight and obese)
2.12(S) Prevalence of obesity in adults (16+)
2.13 (ii) % of Adults classified as “inactive”
4.4(ii) Preventable Mortality from Cardiovascular disease (including heart disease and stroke)
4.5(ii) Preventable Mortality from All Cancers.
1.2 This service specification relates to a Tier 3 specialist multi-disciplinary team (MDT) service
for adolescent and adult obesity providing specialised support and advice in line with NHS
England policy1
1.3 The service will accept referrals for clients with a Body Mass Index (BMI) ≥ 35kg/m2 with
co-morbidities; clients of South Asian origin with a BMI ≥ 32kg/m2; BMI ≥40kg/m2 with or
without co-morbidities; aged 15 years and upwards; registered with a Sheffield General
Practitioner (GP).
1.4 The service will provide a multidisciplinary assessment of referred clients, design and deliver
a personalised, weight management programme, based upon the published evidence base,
including NICE Guidance CG 43.
1.5 The service will offer the option of a 12 month patient led programme of care and support to
all referrals with follow up to assess long term behaviour change at the agreed times.
1.6 For people who attend as part of the bariatric surgical pathway the service will offer a
programme of care and support in line with NHS England policy ( a minimum programme of
12 months supported programme with a BMI ≥40kg/m2; 6 month supported programme with
a BMI ≥50kg/m2). A full assessment will be made of every person prior to referral for
bariatric surgery to assess behaviour change. The importance of behaviour change prior to
surgery will be emphasised at the start and throughout the programme.
1.7 Providers must co-operate and collaborate with GPs, community services and acute
specialist services providers to ensure that patients entering and exiting the service are
managed appropriately.
1.8 The service will be commissioned via a single contract and will start on the 1st October 2014.
Mobilisation of the service will commence in August 2014.
1
NHS England policy 2013.
2.1 National context and evidence base
Obesity is a medical condition in which excess body fat accumulates to the extent that it may
have an adverse effect on health, leading to increased health problems and reduced life
expectancy. Obesity is a risk factor for a number of serious health problems including
cardiovascular disease, some cancers (liver, colon, renal, prostate, breast, endometrial,
ovarian), respiratory disease, depression, obstetric risk, joint pain and Alzheimer’s disease. The
burden of obesity is significant, and it is estimated to be responsible for 58% of all Type 2
Diabetes, 21% of all heart disease, 10% of all non-smoking related cancers and around 9,000
premature deaths per year in England (Butland et al 2007).
In England the proportion of adults with a normal Body Mass Index (BMI) decreased between
1993 and 2012 from 41.0 per cent to 32.1 per cent among men and from 49.5 per cent to 40.6
per cent among women. During the same period there was an increase in the proportion of
adults with a BMI ≥30kg/m2 with a rise from 13.2 per cent to 24.4 per cent in men and 16.4 per
cent to 25.1 per cent in women. 2
In England more than 6 out of 10 men (66.5%) aged 16+ are overweight or obese and more
than 5 out of 10 women (57.8%) aged 16+ are overweight or obese.3
Obesity is defined using body mass index (BMI). The classification system for body mass and
the health risks associated with different BMIs is contained in Appendix 1. It is estimated that
people with a BMI of 30-35kg/m2 will, on average, lose 2-4 years of life and people with a BMI
of 40-45kg/m2 will, on average, lose 8-10 years of life (Prospective Studies Collaboration,
2009).
The causes of, and influences on, obesity are many and complex. Society has changed rapidly
in recent generations, with major changes to the way we work, the way we move and travel, the
food that is available, the way we consume food, and the leisure activities we take part in.
These changes have exposed an underlying biological tendency, possessed by many people, to
put on weight and retain it. In 2007, the Foresight Report Tackling Obesities: Future Choices
mapped the many factors which influence obesity and produced an ‘obesity systems map’ which
demonstrated the complexities of obesity (see appendix 2). The report also introduced the term
‘obesogenic environment’ which is now widely used to describe the fact that the wider
environment (including physical space) plays a fundamental role in the development of obesity.
The health costs of treating obesity are well documented and are set to rise as the growing
numbers of obesity will increase the likelihood of long term conditions like diabetes. The social
care costs required for morbidly obese people are equally as costly as homes often require
adaptations to allow a person to remain within their own environment along with carer provision.
Adaptations can include stair lifts, wider door frames, bathing equipment including hoists for
bathing and moving the person from the bed to chair. The often over looked costs to obesity
include areas such as continence services; including sanitary collections as well as the need for
more than one carer per visit to attend to a individuals basic requirements due to their
immobility. Social isolation due to poor mobility and low self-esteem often places increased
2
3
Statistics on Obesity, Physical Inactivity and Diet, Health and Social Care Information Centre (February 2014)
Health Survey for England (2010-2012)
dependency on health and social care services. These costs are likely to increase with rising
levels of obesity.
Work to tackle obesity supports the policies on Building Health4, NICE guidance on physical
activity and the environment5 and the National Planning Policy Framework which includes the
requirement for planners to promote healthy communities and support the Joint Health and
Wellbeing Strategy6
Obesity is a complex issue, but there are some key issues which should be noted when
considering how to tackle it.
Maternal obesity
In 2011/12, the number of Sheffield mother’s with a known BMI at the time of their antenatal
booking who were overweight, obese or morbidly obese was 67.9% with 23.1% of them being
obese or morbidly obese7.
Table 1: Shows the number of Sheffield mothers with a known BMI who are overweight, obese
or morbidly obese at booking8.
Maternal obesity is an established risk factor for increased complications during pregnancy and
in the post-natal period compared to their counterparts who have a healthy BMI. Findings from
the Centre for Maternal and Child Enquiries (CMACE) observational study showed correlation
between increasing levels of obesity and an associated increase in hypertension, gestational
diabetes, instrumental delivery, caesarean section, induced labour, postpartum haemorrhage,
4
Building Health
NICE Physical Activity and the Environment
6
National Planning Policy Framework.
7
BMI of Sheffield mothers. Statistical Report (2014), Public Health Intelligence Team, Sheffield, City Council.
8
BMI of Sheffield mothers. Statistical Report (2014), Public Health Intelligence Team, Sheffield, City Council.
5
foetal abnormality, stillbirth and special care baby unit admissions.9 Obese women are more
likely to spend more days in hospital and the increased levels of complications in pregnancy
increases the cost of antenatal care compared to women within the healthy weight range.
Babies born to obese mothers have an increased risk of admission to neonatal intensive care
compared to babies born to mothers of a normal weight10.
Maternal obesity is a known risk factor for both maternal and infant mortality. In an enquiry into
maternal deaths the BMI was known for 227 women (87%). 47% of mothers who had died from
direct causes (pre-eclampsia, eclampsia, anaesthesia, acute fatty liver, thrombosis) were either
overweight or obese. 50% of women who died from indirect causes (cardiac disease, psychiatric
and neurological cause) were overweight or obese11. (See table 2)
Table 2: Body Mass Index by Direct and Indirect maternal death for women who had a BMI
recorded; UK: 2006-2008
In 2009, 25% of mothers who had stillbirths and 23% of mothers whose babies died in the
neonatal period had a BMI ≥ 30kg/m2 or more at booking12. In 2010-11, of the infant deaths in
Sheffield, 22.2% were to mothers who were obese at booking Tackling maternal obesity
effectively requires intervention pre-pregnancy through wider initiatives to prevent and treat
obesity in the adult population.
Obesity and disability
There is a two-way relationship between obesity and disability in adults e.g. adults with
disabilities are at higher risk of obesity than those who do not have disabilities and obese adults
9
Maternal obesity in the UK: findings from a national project. (2010), CMACE, UK. (page 7)
NICE public health guidance 27, Weight management before, during and after pregnancy, July 2010.
11
Saving Mothers’ Lives .Reviewing maternal deaths to make motherhood safer: 2006–2008, Volume 118,
Supplement 1, March 2011, page 46
12
Saving Mothers’ Lives .Reviewing maternal deaths to make motherhood safer: 2006–2008, Volume 118,
Supplement 1, March 2011
10
may experience disabilities related to their weight. Among people with severe obesity,
limitations in mobility-related activities have been reported to be between 5 and 9 times greater
than for people of healthy weight. One third of obese adults in England have a limiting longterm illness or disability compared to a quarter of the general population (PHE 2013).
According to the Department for Work and Pensions (2012) the most prevalent disabling
conditions based on UK DLA claimants in 2010-11 were arthritis, mental health, learning
difficulties, diseases of the muscles, bones and joints and back pain. There is a recognised
association between obesity and arthritis, back pain, mental health disorders and learning
disabilities.
The combination of rising obesity and disability levels has significant implications for health and
social care services in England.
2.2 Local context and evidence base
Based on national estimates, obesity leads to approximately 90 premature deaths per year in
Sheffield. The costs of obesity to both health services and wider society are significant. In
Sheffield, the estimated annual direct cost of treating obesity and its consequences is £11.5
million. The estimated annual cost of obesity related sickness absence in Sheffield is £14.5
million. It is estimated that by 2015, obesity and its consequences will cost Sheffield £165
million per year (House of Commons Health Select Committee, 2004).
Based on available validated practice data (n=356,000) 32% (n=115.065) of Sheffield’s over 15
year old population are overweight and a further 21.3% (n= 83.816) have a BMI ≥30kg/m2 to
BMI 60kg/m2. This equates to a known figure of 198.881 people who are overweight or obese
in the city. Of these, over 11,000 are recorded as being severely obese (BMI ≥40). 13
These numbers are underestimated and are based on available data collected by general
practices in Sheffield. However, they demonstrate the scale of the problem in Sheffield and the
need for a clear pathway for weight management in the city which will prevent overweight and
obesity and treat those who have become ill or/and incapacitated as a result of obesity.
Based on data released by Public Health England in February 2014, the number of overweight
and obese people in Sheffield is higher at 59.9% (England average is 63.8%)
13
Public Health Intelligence data (January 2014)
2.3. Overview of the local obesity services and obesity care pathway
Figure 1: Shows the universal adult obesity model and the proposed services for Sheffield
Adult Obesity Model
Tier 4:
Surgery
Tier 3: Specialist
Weight Management
(MDT), drug therapy
Tier 2: Early intervention,
primary care, lifestyle support,
community weight management
Tier 1: Universal Population wide prevention
activity
Proposed model for Sheffield
Tier 4:
Surgery
Tier 3: MDT – 12 month programme with the
exception of patients who have a BMI ≥50kg/m2
accessing as part of the bariatric pathway.
Patient directed service, full assessment for
bariatric patients with regards to the readiness for
surgery and behaviour change during the
programme
Tier 2: Weight management groups to overweight and obese people at an early
stage where front line staff have identified someone needs more intensive support.
Pathway developed to support people pre-conceptually to achieve a healthy
weight and to identify and support overweight and obese pregnant women who
present at booking. Pathway developed and adopted in general practice to support
early identification and treatment of overweight and obesity within the general
population. Link closely into the Sport and Physical Activity Referral Programme,
Cook and Eat sessions, Health Champions, Move More Plan. Close links to child
weight management programme.
Tier 1: Brief intervention and universal weight management training for all front-line staff to
ensure a consistent message is given regarding food and physical activity, confidence and
awareness raising around early identification and treatment of overweight and obesity, and
ensuring all staff are aware of the services available that they can refer into to support healthy
weight for the adult population.
2: Scope of the service
2.1 Aims of the service
The aim of the service is to provide an effective and efficient service for people who are
seriously overweight, with or without co-morbidities, to promote life- long behaviour change and
attitudes towards food and physical activity and provide care and support with their
psychological problems.
2.2 Objectives of the service
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To promote long term behaviour change by offering a programme which promotes
physical activity and reduces sedentary behaviour; promotes healthy eating and
supports the psychological barriers to unhealthy relationships with food; supports and
recognises the relationship between mental health and obesity and offers a system
throughout the programme which will support the psychological needs of everyone who
attends.
Given the high prevalence of psychiatric co-morbidity the service will ensure all referrals
are screened for psychological and lifestyle issues which may interfere with their
engagement in the programme.
Ensure that psychological support is offered through a variety of networks E.g. close
links to IAPT, Cognitive Behaviour Therapy (CBT), Psychologist, Mental Health Nurses.
To reduce number of people living with severe obesity, improve the long term health of
the people of Sheffield and reduce the burden of disease and need for social care
Prepare people who have severe obesity for bariatric surgery by supporting them to
understand the risks of the surgery, the need for behaviour change both pre and postoperatively and to assist in the decision making process.
Reduce the incidence of the prescribing of anti-obesity drugs and ensure that they are
only prescribed within a supported programme.
2.3 Inclusion and exclusion criteria
Inclusion
2.3.1
2.3.2
2.3.3
2.3.4
The service will take referrals from male and female young people and adults, 15 years
and over who are registered with a Sheffield General Practitioner (GP)
Provision must be made to accommodate parents/ guardians and carers where
appropriate and with the permission of the individual, for them to support and be
involved with the treatment plan.
Referrals will be accepted from a range of professionals including, Sheffield GP’s,
Primary Care Staff, specialist secondary care services (E.g. diabetologist, cardiologist,
rheumatologist, musculo-skeletal services (MSK), sleep apnoea)
Referral will be accepted for people:
With co-morbidities: BMI ≥35kg/m2 or BMI ≥32kg/m2 for individuals of South Asian
origin.
Without co-morbidities: BMI≥40kg/m2 or BMI ≥35kg/m2 for individuals of South Asian
origin.
2.3.5
2.3.6
2.3.7
2.3.8
The service will accept referrals for individuals who are seeking bariatric surgery as well
as from patients who are not. This programme will form part of the bariatric surgery (Tier
4) pathway and will support individuals both pre and post- surgery in line with NHS
England guidance.
The individual must be motivated to attend appointments regularly and be ready to make
behaviour changes with regards to their diet and physical activity levels. The service
must emphasise the importance of these changes and commitment even if the individual
is seeking surgical intervention.
The service may be required on occasions to accept a referral for a under 15 year old
where there is no other service available to offer support and it is felt that the
adolescents weight is causing lime limiting health problems. The referral will only be
accepted following discussion with the commissioner and where the service feel it is safe
and appropriate to do so.
The service will be part of the maternal pathways and will offer support where necessary
to pregnant women and will offer prompt referral for women and their partners planning a
pregnancy. This service will link closely to the tier 2 service and offer prompt access to
pregnant women if they require more specialist intervention than tier 2 can provide.
Exclusion
2.3.9
The service will not accept referrals from individuals who have a BMI less than that
stated in the inclusion criteria.
2.3.10 The service will offer a specialist Tier 3 MDT and will not accept referral for individuals
requiring Tier 1 or Tier 2 services.
2.3.11 The service will not include aspects which should routinely be offered by other service
providers.
2.4 Referral route and service outline.
2.4.1
2.4.2
2.4.3
2.4.4
2.4.5
The service will accept referrals using an appropriately designed referral form from
general practioners (GP) and primary care staff; specialist secondary care services (E.g.
diabetologist, cardiologist, rheumatologist, musculo-skeletal services (MSK))
The referral form will be issued to all potential referral sources and will be added to
appropriate intranets for ease of use.
Following referral the individual will be offered a first appointment where they will be
seen within two weeks of the referral date.
The first appointment where possible and agreeable and appropriate for the individual
will be a group assessment where the programme will be described and the individual
commitment that will be required will be outlined E.g. willingness to attend sessions and
change behaviour.
A multi-disciplinary team (MDT) assessment will be carried out to establish clinical,
psychological, social and lifestyle information about the individual to enable an
individually tailored programme to be drawn up. It is essential at this point that
information is gathered about the individual’s current diet and physical activity levels as
well as assessing again their readiness to change and their support networks.
2.4.6 Where it is clear that the individual has unresolved psychological or mental health
problems which are likely to prevent them from fully engaging with programme a
professional decision should be taken to refer to psychological services (E.g.
IAPT/Psychologist) for assessment and treatment before or in partnership with the
weight management programme.
2.4.7 The individual should be given up to two weeks to decide if they are willing to commit to
the programme and will be expected to sign a contract with the service.
2.4.8 If a decision is made by the individual not to continue on the programme a letter should
go back to the referrer alerting them to this.
2.4.9 If an individual makes the decision to sign up to the programme they must be informed
that they will be assessed at 12 weeks and again at 6, 9 and 12 months. The importance
of these follow ups must be emphasised and it should be made clear that if the individual
fails to commit fully to the programme they may be asked to leave the programme. At
each of the assessment points a personal programme will be set with the individual for
the following 12 weeks. Motivation will be assessed on weight loss, physical activity and
dietary behaviour change and attendance and engagement with the programme.
2.4.10 Following sign up and MDT assessment an individually tailored programme for the first
12 weeks will be provided to all motivated individuals. The outcome objectives of the
programme will be:
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Weight loss and a reduction in BMI
Long term behaviour change and attitudes towards diet and physical activity
Improved self esteem
Referral to existing services which support behaviour change and encourage where
appropriate socialisation and reduce isolated behaviour
As part of the individual programme the service will ensure people have:
 A named therapist who will oversee their first 12 weeks of the programme and make
amendment/additions to the programme in consultation with the client as deemed
necessary.
 A named contact (buddy) who will contact them by telephone, email, text or letter every
week or as often as is required by the client.
 Support to make small changes that will have long term benefits to their health and
wellbeing
 Support and information to make healthy choices that are well within their capabilities
and with support and encouragement will become the norm for them
 Make decisions on realistic and healthy weight loss and goals that can be achieved and
maintained for life
 Encouragement and support to those who are attending for weight loss surgery to
consider that they may be able to make these changes without surgical intervention.
 Help and support to be able to assess their weight against recommended BMI scores
 Advise and provide support for long term lifestyle changes using a healthy eating
approach, a programme of physical activities and psychological support
 Advice on behaviour change techniques, such as keeping a diary and advice on how to
cope with difficult situations and a focus on making small achievable long term changes
 Have emotional and wellbeing support to increase levels of self esteem
 Information about other services which will build on what is offered from this programme
E.g. physical activity referrals schemes, drop in sessions throughout the week, cook and
eat sessions to help with healthy cooking skills.
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Helpline and email support systems to encourage ongoing commitment to making
changes.
2.4.11 The service are expected to follow up people at 12 weeks,6,9 and 12 months and at
each point the MDT will assess progress and weather the individual continues and plan
as in (2.4.8) for the following 12 weeks.
2.4.12 A letter must be sent to the referrer and GP (if not the same) at each point of
assessment to update the referrer of progress and highlight any areas where additional
support is required outside of the programme.
2.4.13 A letter must be sent to the referrer and GP (if not the same) if the individual drops out of
the programme or does not attend the initial assessment to ensure they are followed up
and supported.
2.4.14 The service are expected to establish support groups which will meet on each day of the
week at various times of day to accommodate people who work and includes evening
and weekend sessions
2.4.15 The service are expected to establish programmes across Sheffield targeting the most
deprived areas and where there is the highest need. Services should be established
where there are easily accessible good public transport links, have easily accessible car
parking facilities and have disabled access. As people progress through the programme
they should be encouraged to build active travel into their programme where possible.
2.4.16 Where the patient has established comorbidities, these should be managed throughout
the programme by the GP. Where it is seen necessary to change treatment
programmes, this should be in liaison with the patients GP.
2.4.17 Anti-obesity medication should only be prescribed in partnership with the individuals GP.
2.4.18 The provider must ensure that they work with Tier 1 and Tier 2 services and any current
care pathways and prevention/screening services currently provided by primary or
secondary care; Clinical Commissioning Group (CCG) and other local providers
2.4.19 In line with best practice, pathways and protocols should be developed by the service to
show how the following will be managed:
 Referral into the service
 Referral into Tier 1and 2 services which support the work of this programme.
 Successful discharge back to the referrer or/and GP for ongoing support and long term
management
 Referral into the Tier 3 service.
 Support pre and post Tier 3.
 Bariatric surgery pathway.
Bariatric referrals
2.4.20 Where people are attending as part of the bariatric pathway in line with NHS England
policy, regardless of BMI and the time they will be required to spend with the service, it
must be made clear at the outset that they must engage with the programme in order for
them to progress to surgery and that it is essential that they make behaviour changes
prior to having surgery.
2.4.21 They should be assessed at 12 weeks and if they have failed to engage with the
programme a discussion should first be had with the individual to identify reasons for this
and emphasise again the importance of making behavior changes. If they are motivated
to continue, they should be allowed to progress with support and assessed again at the
2.4.22
2.4.23
2.4.24
2.4.25
end of a further 12 weeks. If they fail to engage a conversation with the secondary care
surgical team should be had before they are able to progress in the programme.
The second 12 weeks of the programme will continue as the first 12 with individuals
being challenged to E.g. increase physical activity levels with referral for additional
support being offered to the Sport and Physical Activity Referral Scheme.
At the end of the second 12 weeks, patients attending a programme with a BMI
≥50kg/m2 who have chosen surgical intervention will be referred to secondary care for
support but will be encouraged to continue to attend the drop in support session prior to
and post- surgery as required.
For those referrals with a BMI≤50kg/m2 they will continue to be assessed at 9 and 12
months and an individual plan as before be offered with referral if not already made to
additional support services E.g. Sport and Physical Activity Referral, Cook and Eat
sessions.
At the end of the 12 month period the individual will be supported as (2.4.22)
Existing service users
It will be the responsibility of the new provider to liaise with the existing service provider and
ensure that there is a continuation of care for all existing service users. It will be the existing
provider’s responsibility to ensure that all existing service users are contacted and informed of
the change of provider and that it is agreed that information can be shared. Data sharing and
confidentiality are to be maintained and information governance adhered to at all times.
3. Monitoring and evaluation
3.1 Outcomes.
Outcome
Equitable access and outcomes within the
target population
Demonstrated by
Annual EIA and development of an
action plan which will be reported on at
quarterly monitoring meetings.
Taking into account and monitoring the
age, sex, deprivation quintile, disability,
race, religion of the population group
and ensuring no group is
excluded.(reported quarterly)
50% of people to come from highest
areas of deprivation.(reported quarterly)
Target work within BME communities
demonstrated by 1) 20% increase in
year 2 and 3 from the year 1 baseline of
the number of people being referred 2)
20% increase in year 2 and 3 from the
baseline in year 1 of the number of
people who complete a
programme14(reported quarterly)
14
Reduction in sedentary behaviour
IPAQ and BREQ2 (motivation and
confidence to exercise) to be completed
at the initial assessment to ascertain
levels of activity on entering the
programme. Repeated at 12 weeks, 6,
9 and 12 months and should
demonstrate a sustained increase in
daily activity and sustained reduction in
the time spent sedentary.(reported
quarterly number of sedentary people
moving to 1x30 minutes activity a week
and those achieving 150 minutes a
week at each stage)
Report on the number of people
referred to the Sport and Physical
Activity Programme
Effective and efficient weight reduction.
60% of people should demonstrate a
3% weight loss at 12 weeks. This
should be maintained at 6 months
60% of people should demonstrate a
5% weight loss at 6 months maintained
at 9 and 12 months.
Bariatric patients should demonstrate a
sustained weight loss as above. If this is
not achieved the service must discuss
their lack of progress and behaviour
change with the bariatric surgeons
60% of service users to demonstrate a
reduction in BMI at 3,6,9 and 12 months
(or as long as they remain within the
service15)
80% of service users to demonstrate
weight loss throughout the programme
reported at 3, 6, 9 and 12 months.
Improved dietary intake
Eat well plate, increased fruit and
vegetable intake measured using a
validated tool as suggested by the
National Obesity Observatory (NOO)
Waiting times and access
100% of people will be contacted within
2 weeks of their referral and offered an
There is no set time limit on a completed programme as the service will be individually tailored and therefore
some people will need more support than others. However the minimum period of time should be agreed at 6
months for behaviour change.
15
People entering the programme with a BMI>50kg/m2 will only remain in the service for 6 months.
Patient satisfaction and improved quality
of life
Pharmacological interventions
appointment to start the programme.
The maximum waiting time should be
no more than 2 weeks.
50% of people who complete 12 weeks
to complete a validated patient
satisfaction survey. 30% of people who
enter the programme but don’t complete
12 weeks to be followed up and
complete the questionnaire.
Complaints and compliments reported
on quarterly and learning recorded
Appropriate validated tool to measure
quality of life
Collect patient satisfaction information
from a sample of people at 6 months
and 12 months (20% of total number of
people who start the programme)
Demonstrate compliant prescribing of
pharmacological interventions in line
with NICE guidance.
3.2. Key Performance Indicators to be reported quarterly by the service
3.2.1 Core data to be recorded before commencing the programme must include:
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3.2.2
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Full Name
Date of Birth
Age
Gender
Ethnicity – using DCSF codes
Ward/Neighbourhood
Registered GP
Any learning or physical disability
Details of any pre-existing risk factors and co-morbidities
Long Term Sickness
Follow up plan discussed and the importance of this discussed.
Key Performance Indicators (KPIs) and information to be reported quarterly:
Total number of referrals received by the service.
Total number of referrals who are given a first appointment

Total number of referrals who are given a first appointment who start the programme =
910
 Total number who start the programme who complete IPAQ =100% (910)
 Total number who start the programme who complete Sheffield Food Tool = 100% (910)
 Total number who start the programme who complete Rosenberg self-esteem =100%
(910)
 Total number of referrals who are contacted by the service within 2 weeks of the referral
letter being received = 100%
 Percentage of referrals from the lowest 2 quintiles = 50%
 Total number of referrals who take up a first appointment completing 12 weeks = 819
(90% of starters)
 Total number of referrals who take up a first appointment completing 6 months = 409
 Total number of referrals who take up a first appointment followed up at 9 months = 246
 Total number of referrals who take up a first appointment followed up at 12 months =
246
 Number of referrals initially referred as part of the bariatric pathway =
 Number of referrals initially referred as part of the bariatric pathway who choose not to
have surgery
Weight reduction
 Record BMI for all starters (please supply a list of BMIs to the commissioner to enable
them to calculate mean BMI.
 60% of total referrals to demonstrate a 3% weight loss at 12 weeks = 546*
 Maintained 3% weight loss at 6 months = 546*
 Number who have gained weight=
 60% of referrals completing a 12 week programme to demonstrate a 5% weight loss at
6, 9 and 12 months = 54616
 70% of starters should demonstrate a reduction in their BMI on completion of the
programme = 637*
 Record all BMIs on completion and submit to commissioner to allow for calculation of
mean BMI.
 Record number and weight loss in kg at 12 weeks, 6, 9 and 12 months = 0-5kg; 5-10kg;
10-15kg; 15kg plus; record the percentage of referrals with weight loss.
 Number of people completing a 12 week programme who complete IPAQ, Validated
Food Tool and Rosenberg = 819
 Number of people who complete a 12 week programme who move from sedentary to
doing 30 minutes activity a week (10 minute blocks) maintained at 6 months = 810
(100% of completers)
 Number of people who complete a 12 week programme increase their physical activity
level by 60 minutes of activity in a week (against their baseline measure) maintained at 6
months = 648 ( 80% of 12 week completers)
 Number of people completing 6 months completing IPAQ, Validated Food Tool and
Rosenberg = 50% of 12 week completers = (409)
 Number of people who complete a programme 12 week programme who are achieving a
150 minutes of physical activity a week at 6 months = (50% of 12 week completers) 409

16
Whilst this is a patient led service and people may not choose to continue in the service up to 12 months, where possible, it should
be agreed with the person at the start that the service will be required to follow them up at regular intervals to see how effective the
time they spent in the service was in making long term behaviour change.






3.2.1
3.2.2
Number of people to be followed up at 9 months completing IPAQ and Rosenberg =
30% of 12 week completers = (246)
Number of people who complete a programme 12 week programme who are achieving a
150 minutes of physical activity a week at 9 months = (30% of 12 week completers) 246
Number of people to be followed up at 12 months and complete IPAQ and Rosenberg =
30% of 12 week completers = (246)
Number of people who complete a programme 12 week programme who are achieving a
150 minutes of physical activity a week at 12 months = (30% of 12 week completers)
246
Record the change in score at 12 weeks, 6, 9 and 12 months for all those followed up
(numbers as shown for physical activity) for improvement in self-esteem using
Rosenberg self-esteem.
Record the changes in eating habits at 12 weeks, 6, 9 and 12 months (numbers as
shown for physical activity) using the Validated Food Tool.
Written consent must be obtained from people from the outset to ensure that data can
be collected in the future in order to demonstrate long term impact of the service. People
should be made aware that in order to refer them to an appropriate service some
information will need to be shared i.e. contact details, reason for referral.
The provider must stress the importance of data collection to the provider service. They
must ensure the provider has its own confidentiality policy and safe and locked storage
facility for referral forms to be stored.
3.2.3
Participants must be followed up at twelve weeks, six (26 weeks), nine (38 weeks) and
twelve months (52 weeks); week one being classed as the week they begin the
programme.
3.2.4
The provider must have systems in place to monitor and maintain the quality of the
service provision. This will include:


A written complaints procedure
Routine information from participants about their satisfaction with the service provided
3.2.5
Initially monitoring meetings will be set monthly until the service becomes established
between the provider and commissioner at which a performance monitoring report (as
established by the contract manager) will be provided by the provider. These meetings
will also provide a forum to discuss the on-going development of the service and resolve
any difficulties.
3.2.6
Thereafter, quarterly monitoring meetings will take place between the provider and
commissioner, at which a performance monitoring report will be provided by the
provider.
3.3 Finance

The financial envelope available for this service is £400k per annum



85% of the contract value (£340k) will be paid on block. Payments are made on a
monthly basis, 30 days in arrears upon receipt of invoice.
The financial envelope includes the costs of room hire, interpreters, community
transport, staff training and no additional funding will be made available at any point by
the commissioner to cover these or any other additional costs.
15% of the contract value (£60k) relates to bonus payment will be awarded as follows:
1. Patient satisfaction
(50% of the bonus payment relates to this area. (£30k))
 The provider will use a validated tool to collect patient satisfaction
information from a sample of people who complete a12 weeks (50%) and
a sample (30%) from those who begin a programme but do not complete
12 weeks.
 The provider will collect patient satisfaction information from a sample of
people at 6 months and 12 months (20% of total number of people who
start the programme)
 At least 90% of the people surveyed should report satisfaction with the
service.
 The provider will provide quality feedback on how the service is achieving
people’s objectives and how reasonable suggestions on improving the
service will be implemented.
 Payment will be made quarterly in arrears upon receipt of patient
satisfaction information results.
2. Successful Weight Loss
(50% of the bonus payment relates to this area (£30k))
 60% of people completing 12 weeks will lose 3% of weight at 12 weeks
maintained or increased to 5% at 6 months.*(shown in the KPIs)
 70% of starters should demonstrate a reduction in their BMI on
completion of the programme = 637*(shown in the KPIs)
 Payment will be made quarterly in arrears, and an adjustment made if
necessary upon receipt of KPI information
4. Service standards
Equity and access
4.1 The provider is required to ensure that services are offered at suitable locations and
where possible on public transport routes to encourage physical activity and reduce
where feasible car use. However, the provider must ensure that there is easily
accessible car parking space at all venues for those who choose to use the car
4.2 Services should be offered at times throughout the day and outside core working hours
to accommodate individuals who work and appointments should be flexible to
accommodate E.g. shift workers and individuals with caring responsibilities; provision in
the evenings and at weekends.
4.3 Services should be accessible and tailored to the needs of different groups and
communities and the provider will ensure that groups are offered at a number of
locations across Sheffield as well as identifying a suitable central location to maximize
accessibility.
4.4 The provider should ensure that services and support are delivered in a variety of ways
to allow for personal preference, comfort and maximize attendance and positive
messages E.g. groups, 1-1s, support sessions, email, text.
4.5 The provider is responsible for risk assessing any venue and ensuring it is safe,
accessible for individuals who are disabled or who may have poor mobility; be clean and
have toilets and hand washing facilities.
4.6 Services must be delivered in a way which respects and recognizes seen and unseen
needs and preferences of target groups which include: gender, cultural and faith groups;
disability (physical and learning); black and minority ethnic groups; sexuality.
4.7 The provider is required to complete an annual Equality Impact Assessment (EIA) and
action plan to challenge discrimination, promote equality and respect the individual’s
human rights. This will form part of the quarterly monitoring.
4.8 The provider should have reasonable access to interpreter services and language
barriers must not be a barrier to anyone being able to access the services provided.
4.9 Where possible individuals should be encouraged to make their own arrangements to
attend the service but where it is indicated by the referrer that the individual will require
community transport the responsibility to organize this will be with the service provider.
4.10
It is the responsibility of the provider to ensure all referrals sources have
knowledge of the service and are aware of the referral criteria and route of referral.
4.11
Waiting time from referral to the first appointment should not exceed two weeks.
If the provider is aware that the waiting time is in excess of this then they should inform
the commissioner at the first opportunity.
4.12
The provider at all times must adhere to the relevant Health and Safety and
Security legal requirements.
5. Staff
5.1 The provider is tasked to think innovatively regarding the composition of the MDT.
5.2 The provider will ensure that all clinical staff are appropriately trained and are registered
with the appropriate professional body and registration checked at the annual appraisal.
E.g. Registered Dietician, Physiotherapist, Physical Activity and Nutritional Specialists,
Psychologist, Nursing and Midwifery Council (NMC).
5.3 The service will ensure that all staff are trained to support the emotional wellbeing of all
referrals and are aware of and trained to recognise when more intensive support is
required from E.g. IAPT / Psychologist and referrals made at the earliest opportunity.
5.4 The provider is required to ensure that all clinical staff receives clinical supervision in line
with their professional body.
5.5 All staff are required to be CRB checked
5.6 All staff should have regular 1-1s with their line manager and receive an annual
appraisal.
5.7 All staff should demonstrate evidence of Continued Professional Development (CPD)
5.8 The service must follow Clinical Governance policy in line with their organisation.
The service provider has a responsibility to ensure that all staff who are working outside
core office hours have adequate reporting arrangements to ensure their personal safety.
Where ever possible staff should be double crewed out of hours. If it is necessary for
staff to work alone then there must definitely be a process for reporting when work is
completed E.g. report when they finish work to the out of hours team or other team
member and the service must ensure the lone worker policy is implemented and staff
are fully engaged.
5.9 The provider will institute management and administrative arrangements with clear lines
of accountability, including an identified lead clinician/manager with overall responsibility
for the service. The designated manager will be responsible for:

building and maintaining relationships with other local agencies;

liaising with and reporting to the commissioner, Sheffield City Council/ Clinical
Commissioning Group;

Overseeing recruitment as appropriate;

Line managing and supporting other staff involved in the service.
5.10
The provider must adhere to their service Commissioning and Quality Strategy in
relation to all workforce issues.
5.11
All staff recruited to deliver this service must be made aware about the
importance of maintaining a high standard of performance and their lines of
accountability. They should be encouraged to identify areas where they require further
training and support and refresher courses and updates should be available for staff to
access.
5.12
It is the service providers responsibility to ensure that staff have the appropriate
indemnity insurance in place should a claim be made against an individual or the
service. It is the responsibility of the provider to check any documentation which should
be submitted on request to Sheffield City Council/ Clinical Commissioning Group
5.13
The service provider must ensure that all staff recruited to work within this
programme have the ability, appropriate skills, up to date training and experience to
work with this client group.
5.14 In addition the service provider will:




Be able to demonstrate their capability in delivering a successful Multi -Disciplinary
Team programme by providing evidence from the last 12 months.
The provider will demonstrate the ability to recruit and retain staff that are
appropriately skilled and will be required to develop a workforce plan to prevent
any disruption in service delivery in the event of long term sickness absence or
staff leaving.
The service will at all times maintain close links with referral sources and ensure
that referrers E.g. GPs are kept informed about the individuals progress.
The service are required to maintain close links with the acute services provider
and work in partnership to ensure the service being offered meets the needs of
those people who will be accessing bariatric services both pre and post
operatively.
6. Quality
1. REGULATION AND
LEGISLATION
1a. INFECTION CONTROL
Systems are in place to
ensure appropriate infection
Infection control policy in place which includes procedures
and staff training for:
Hand washing
Sharps
Waste management
Decontamination
control procedures are in
place
1b. COMPLIANCE WITH
EQUALITY AND HUMAN
RIGHTS LEGISLATION
Audit reports and action plans
Participation in Root Cause Analysis of MRSA
bacteraemia cases if relevant
Policies include legislation for equality and human rights specifically
Race, Disability and Gender.
Equality data is collected and used to improve access to
services
Impact assessments undertaken on policies and services
Consultation on new services in respect of equality
2. PATIENT SAFETY
2a. INCIDENT REPORTING
Clear systems are in place to
ensure all clinical untoward
incidents / near misses are
reported, investigated, action
plans in place, implemented
and monitored.
Incident Reporting Policy in place
Incidents/significant event reports and reviews
Annual Report of all incidents - evidence of learning and
changes to practice
Practice / team meeting notes
2b. SERIOUS UNTOWARD
INCIDENTS (SUI) including
‘Never Events’
Procedures in place to report to the SCC within 2 days.
Action plans for each SUI and updates on progress
2c. CENTRAL ALERT
SYSTEM (CAS)
Policy/procedures for receiving and implementing alerts
2d. SAFEGUARDING ADULTS
AND CHILDREN
Policy and Procedures in place; routinely visited as part of
staff appraisal and adhered to. Staff fully aware of the
reporting arrangements at all times.
Safeguarding and Mental Capacity Act, Deprivation of
Liberty (DOL) training for staff
Procedures for undertaking CRB checks
3. CLINICAL and COST
EFFECTIVENESS/AUDIT
3a. Systems are in place to
deliver evidence based
practice.
Evidence based Protocols / guidelines / policies in place
that include and reflect national guidance especially, but
not exclusively, from NICE.
3b. An annual audit
programme is in place
Audit programmes for national / local priority guidelines
that demonstrate compliance with national guidance.
Action plans for improvement and demonstration of
implementation.
4. GOVERNANCE AND RISK
MANAGEMENT
4a. Systems are in place to
ensure premises,
Risk assessments reports and plans Health & Safety
checks
Fire safety checks
environment and equipment
are fit for purpose
Equipment maintenance checks
Procedure for Reporting of Injuries, Diseases &
Dangerous Occurrences (RIDDOR)
4b. Systems are in place to
ensure all the necessary
employment checks are
undertaken
Checking procedures for:
Indemnity certificates
Professional Registration
Professional Qualifications
4c. Systems are in place to
ensure job descriptions and
contracts are in place and
reviewed appropriately
Job descriptions
Contracts
4d. Systems are in place to
ensure staff receive
Continuous Professional
Development, relevant
training
Annual Appraisal of staff
Personal Development plans
Supervision /mentoring arrangements
Training records for essential training
 Fire
 Basic Life Support
 Confidentiality
 Sharing of Information Governance
 Equipment training records
 Child and adult protection training
4e. Staff satisfaction
Annual staff survey with action plan
5. PATIENT EXPERIENCE
AND INVOLVEMENT
5a. Systems are in place to
ensure all complaints are
investigated, appropriate
action taken and learning
takes place
Policies / procedures
Compliments / Complaints / PALS reports
Evidence of learning from complaints / changes to practice
5b. Systems are in place to
ensure patient/public
consultation
Patient / public input into planning and evaluating services
5c. Patient / user experience
is sought and acted on
Annual Patient/ user surveys / feedback mechanisms with
action plans including evidence that patients are treated
with dignity and respect.
Patient reported outcome measures if available
6. EXTERNAL
ACCREDITATIONS /
REVIEWS
Reports and action plans are in place following any
professional, quality, Health and safety, or audit or Local
Involvement Networks (LINKS) visits.
Reviews of services following the introduction of new
legislation, national policy and standards
Appendix 1.
Measurements of weight
(1) Measurement and classification of Body Mass Index (BMI)
BMI is defined as weight in kilograms divided by the square of the height in metres (kg/m2).
Where the prevalence of obesity is referred to in this chapter it is referring to those who are
obese or morbidly obese (i.e. with a BMI of 30kg/m2 or over) unless otherwise stated.
Table 1: Shows the BMI ranges used to define BMI status
Definition
Underweight
Normal Weight
Overweight
Obese I
Obese II
Morbidly Obese
Overweight including obese
Obese including morbidly obese
BMI Range
18.5kg/m2
18.5 to less than 25kg/m2
25 to less than 30kg/m2
30 to less than 35kg/m2
35 to less than 40kg/m2
>40kg/m2
25kg/m2 and over
30kg/m2 and over
(2) Waist circumference
Where BMI looks at the difference in height, it cannot distinguish between overweight due to
body fat or muscular physique. Waist circumference is a recognised tool to identify increased
health due to overweight.
Raised waist circumferences are defined as:
 102cm in men
 88cm in women
(3) NICE health risk categories using BMI and waist circumference
BMI Classification
Normal Weight (18.5 to less than
25kg/m2)
Overweight (25 to less than
30kg/m2)
Obese I (30 to less than 35kg/m2)
Obese II (35 to less than 40kg/m2)
Obese III (>40kg/m2)
Waist Circumference
Low
High
No increased risk
No increased risk
No increased risk
Increased risk
Very high risk
Very high risk
Increased risk
High risk
Very high risk
Very high risk
Very High
Increased risk
High risk
Very high risk
Very high risk
Very high risk