NHS Dorset Clinical Commissioning Group
Access Criteria for Tier 3 Weight Management Programme
Supporting people in Dorset to lead healthier lives
POLICY TRAIL AND VERSION CONTROL SHEET:
Policy Reference: TIER 3 WEIGHT MANAGEMENT PROGRAMME
Policy ID 93 Version: 1
Document History
Date of
Issue
July 2014
Version
No.
V2
Next Review
Date
July 2016
Date
Approved
July 2014
1
Nature of Change
Email address amended and patient
information removed to be replaced by
new Patient Information Leaflet to be
available in separate PDF document
NHS DORSET CLINICAL COMMISSIONING GROUP
ACCESS CRITERIA FOR TIER 3 WEIGHT MANAGEMENT PROGRAMME
1.
INTRODUCTION
1.1
Bariatric surgery is a specialist service and from April 2013 this will be commissioned by
NHS England.
1.2
The National Clinical Policy: Complex and Specialised Obesity Surgery outlines the model
of care for managing obesity as follows:
1.3

Tier 1 – Primary care with community advice.

Tier 2 – Primary care with community interventions.

Tier 3 – A community/primary care based multi-disciplinary team (MDT) to provide an
intensive level of input to patients (Tier 3 WMP).

Tier 4 - Specialist obesity services including surgery.
NHS England requires that all individuals have attended and complied with a local Tier 3
WMP for a minimum of 6 months before referral to Tier 4 services for surgical assessment
to ensure:



all other non-surgical options have been exhausted;
the patient has demonstrated a commitment to lifestyle changes required for a
successful outcome from surgery;
the patient is fit for surgery.
1.4
All providers of bariatric surgery will need to be assured that people have successfully
completed a Tier 3 WMP. (Appendix 1) The access criteria for a Tier 3 WMP, is detailed
below and approval for referral will be made by the Dorset CCG Individual Patient
Treatment (IPT) team. Direct referral to Tier 3 services cannot be made.
1.5
Approval for onward referral to Tier 4 services for bariatric surgical assessment will be
considered by the IPT team following successful completion of the Tier 3 WMP. GP’s will
then be advised if a referral to a surgical service can be made.
1.6
Any patient identified as clinically inappropriate for Tier 3 WMP i.e. the presence of
serious uncontrolled disease or unstable psychiatric disorder, may be considered by the
IPT team for direct referral to Tier 4 bariatric services for assessment and advice.
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1.7
Direct referral to Tier 3 and Tier 4 bariatric services cannot be made by the GP or other
healthcare professionals without explicit approval from the Dorset CCG IPT Team.
2.
TIER 3 ACCESS CRITERIA
2.1
All patients referred to the Dorset IPT Team for consideration for Tier 3 WMP must meet
the NICE guidance for bariatric surgery:

BMI of >35, in the presence of diabetes and/or other significant co-morbid conditions;

BMI >40 without the presence of diabetes and/or other significant co-morbid
conditions.
2.2
Patients will only be considered for referral to Tier 3 WMP if evidence is presented to
demonstrate sustained and co-ordinated Tier 1 and 2 community interventions have been
tried and failed.
2.3
Patients will be aged 16 years or over.
3.
OBESITY MANAGEMENT PATHWAY
3.1
GPs are already required to collect data on any patient with a BMI of 30 or more and offer
lifestyle advice.
3.2
Other non-surgical resources available to control obesity include:

counselling;

psychological assessment and programme;

medication.
3.3
The GP practice of a patient identified as having morbid obesity should identify a health
professional who will act as the advisor to each patient and who will assist in drawing up a
specific programme of non-surgical measures. Regular assessment should be undertaken
to review progress.
3.4
The GP practice will have supported the patient in a co-ordinated way (Tier 2) for at least
three years prior to a request for Tier 3 WMP.
3.5
A request will be accompanied by a copy of the last 2 years individual’s programme drawn
up by the practice and a summary of progress against this programme.
3.6
Patients will only be considered for referral to the Tier 3 WMP, if evidence is presented to
demonstrate sustained and co-ordinated Tier 2 community programmes have failed.
These measures must be documented to show what has been tried, the length of time,
3
and reason for failure. A food diary for the 6 weeks prior to a request for referral to a Tier
3 service will be attached to a referral request.
3.7
The documentation and evidence as set out in the Tier 3 WMP proforma (Appendix 2)
should be submitted by the patient’s GP to Dorset CCG for consideration against the
criterion set out in the NICE guidance. It is the responsibility of the relevant health
professional at the GP practice to complete the bariatric proforma in full. Dorset CCG will
only consider applications where full information is provided.
3.8
Individuals approved for Tier 3 WMP will be referred directly to the service by the Dorset
CCG IPT team. The GP will be notified of this referral.
3.9
On completion of the programme Tier 3 WMP will provide recommendations for each
individual regarding future weight management including appropriateness of referral for a
bariatric surgical assessment.
3.10
Based on these recommendations, the Dorset CCG IPT team will advise the GP if referral
to Tier 4 bariatric services is supported.
4.
PREVIOUS SURGERY
4.1
All patients that have already undergone bariatric surgery can be considered for referral
to Tier 3 WMP. However, they will need to have been supported within primary care in
line with new referrals.
4.2
Where a patient has already undergone bariatric surgery and there is concern clinically
about the surgery, referral to the local surgical service should be considered. This will be
for an assessment of surgical complications and not for repeat bariatric surgery.
REFERENCES
National Institute Of Health And Clinical Excellence Guidance (NICE) Clinical Guideline 43:
Obesity; guidance on the prevention, identification, assessment and management of overweight
and obesity in adults and children, December 2006.
The NHS England Clinical Policy: Complex and Specialised Obesity Surgery
Dorset CCG Policy for Individual Patient Treatments
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Appendix 1
Spire Hospital Southampton - Dorset Tier 3 Weight Management Service
Guidelines for General Practitioners and other Healthcare Professionals
1.
‘The Weigh Ahead’ service is a Specialist Tier 3 Community Weight Management Service
for severe and complex obesity, providing an intensive level of support to patients
through a multi-disciplinary team (MDT) approach. The service has been designed to lead
to better outcomes for your patients and to be more cost effective to the NHS in the
longer term.
The service is hosted by Spire Hospital Southampton with outreach clinics available in
Poole and Ringwood for patients who are registered with Dorset CCG General
Practitioners. To access this service please complete the Tier 3 referral form and submit to
the CCG Individual Patient Treatments Team. The service is unable to accept direct GP
referrals for Dorset patients.
2.
Referral Criteria:
 Patients must be aged 16 or over
 Patients must have a BMI ≥ 35 (with co-morbidities, these being primarily those with
diabetes and/or cardiovascular disease) OR a BMI ≥ 40 (without co-morbidities)
 Patients must have complied with a range of weight loss interventions at Tiers 1 and 2
of the pathway over a 2 year period and have failed to achieve or maintain weight loss
goals.
3.
Significant co-morbidities we accept could include:
• Established cardiovascular disease
• Type 2 diabetes
• Sleep apnoea
• Severe hypertension
• Severe lower limb major joint disease requiring orthopaedic intervention, otherwise
precluded on the basis of a BMI
• Dyslipidaemia
• Patients for whom surgery is dependent on weight loss
We can also accept patients with other related conditions such as metabolic syndrome,
polycystic ovarian syndrome and osteoarthritis.
4.
Service Exclusions:
• Any patient with serious uncontrolled disease, e.g. angina, asthma, COPD, heart
failure, aortic stenosis
• Recent complicated Myocardial infarction and/or awaiting further investigation
• Uncontrolled arrhythmia that compromise cardiac function
• Blood pressure at rest above 180mg Systolic, 120mg Diastolic
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• Clients with an unstable psychiatric disorder
• Acute infection
‘The Weigh Ahead’ Tier 3 Weight Management Service contact details:
Telephone: 02380 764964
E-mail: SPIRE.Tier3DorsetWMS@nhs.net
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TIER 3 WEIGHT MANAGEMENT PROGRAMME REQUEST FORM
To request a patient referral to the Tier 3 Weight Management Programme the completed form should be and submitted to the Individual Patient Treatment
team at: DOCCG.IndividualRequest@nhs.net
Tier 3 requests can be made by GPs or the following other healthcare professionals:


Specialist Dieticians including Diabetes Education Programme Dieticians
Practices Nurses
NHS NUMBER:
PATIENT NAME:
D.O.B.:
At point of request:
PATIENT WEIGHT:
BMI:
At point of request:
PATIENT HEIGHT:
3 months previously:
3 months previously:
6 months previously:
6 months previously:
PRACTICE HEALTH ADVISOR FOR THIS PATIENT
(Contact Name and Telephone number)
Has this patient had previous weight loss, surgical intervention (e.g. gastric band). YES/NO. If yes, detail please.
TIER 1 AND 2 WEIGHT MANAGEMENT HISTORY
1
EVIDENCE (documentation attached where relevant)
including dates and reasons for failure.
CRITERION
REQUIREMENTS / EXAMPLES
Lifestyle programme
Details of support team including GP, any other practice
teams such as nurses, dietician and timescales of the
community support programme to attempt weight loss.
Lifestyle programme
Please attach the last 2 years individual plan agreed with this
patient and the practice and progress against the agreed
actions. We would expect details on non-compliance to be
supplied.
Attachment expected
2
7
NHS NUMBER:
CRITERION
3
PATIENT NAME:
D.O.B:
EVIDENCE (documentation attached where relevant) including
dates and reasons for failure.
REQUIREMENTS / EXAMPLES
Has the practice given help to the patient to self-evaluate
their weekly calorie intake?
Lifestyle programme
Do you believe that the patient understands how their food
intake impacts on their obesity?
4
5
6
Exercise Programme
with regular input
Psychological
Interventions/ Cognitive
behaviour therapy
Drug intervention
Details of progressive exercise programmes and outcomes.
This should include weight and BMI measurements at the
start, during and after the programme. We would expect
details of any non-compliance to also be provided.
Details of any psychological/cognitive behaviour therapy
and/or assessment the patient has received. This should
include details of any specialist service or consultant
involved and the outcomes of that therapy and dates (if
relevant).
Details of drug interventions - this must include start and
finish dates, weights at the start and finish, total weight
loss, reasons intervention stopped including any side effects
experienced.
8
NHS NUMBER:
PATIENT NAME:
D.O.B:
CLINICAL INFORMATION /MEDICAL HISTORY
7
Current Medication
Please supply list of current medication
Urea and electrolytes
8
Recent blood test
results ( within 3
months)
Fasting plasma glucose
HbA1c (if diabetic)
Lipid profile
Liver Function
Thyroid function
Diabetes
Medical history and comorbidities
9
(Relevant clinical
correspondence,
specialist input to be
included with request)
Cardiac pathology including angina, congestive heart failure,
arrhythmias
Hypertension. (Recent Blood Pressure to be provided)
Asthma/COPD or other chronic respiratory conditions
Obstructive sleep apnoea
Severe Arthritis
Severely impaired mobility (reasons)
Depression or other psychiatric/psychological disorders
Allergies or conditions such as coeliac disease
9
BP:
Date:
NHS NUMBER:
PATIENT NAME:
D.O.B:
ADDITIONAL INFORMATION
Are there are any specific clinical contra-indications to the
patient participating in the Tier 3 WMP that you are aware
of?
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Additional information
required to assess for
Tier 3 WMP
Are you aware of any absolute clinical contraindications ( i.e.
aortic stenosis) that your patient CANNOT exercise as part of
the Tier 3 WMP?
Is the patient willing to participate and aware of the lifestyle
changes required to successfully complete the Tier 3 WMP?
Please confirm that the patient agrees to the information
supplied with this request being sent to the Tier 3 WMP
Send completed form to the Individual Patient Treatment Team at DOCCG.IndividualRequest@nhs.net
NHS Dorset Clinical Commissioning Group
Individual Patient Treatment Team
First Floor West
Vespasian House
Barrack Road
Dorchester DT1 1TG
Telephone: 01305 368936
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