Supporting people in Dorset to lead healthier lives

NHS Dorset Clinical Commissioning Group

Access Criteria for Tier 3 Weight Management Programme

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Policy Reference: TIER 3 WEIGHT MANAGEMENT PROGRAMME

Policy ID 93 Version: 1

Document History

Date of

Issue

Version

No.

Next Review

Date

Date

Approved

Nature of Change

July 2014 V2 July 2016 July 2014 Email address amended and patient

information removed to be replaced by

new Patient Information Leaflet to be

available in separate PDF document

POLICY TRAIL AND VERSION CONTROL SHEET:

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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:

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.

1.3 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,

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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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Spire Hospital Southampton - Dorset Tier 3 Weight Management Service

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

Appendix 1

Guidelines for General Practitioners and other Healthcare Professionals

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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.:

PATIENT WEIGHT:

At point of request:

3 months previously:

6 months previously:

PATIENT HEIGHT:

BMI:

At point of request:

3 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

CRITERION REQUIREMENTS / EXAMPLES EVIDENCE (documentation attached where relevant) including dates and reasons for failure.

1 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.

2 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

Appendix 2

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NHS NUMBER: PATIENT NAME: D.O.B:

CRITERION REQUIREMENTS / EXAMPLES EVIDENCE (documentation attached where relevant) including

dates and reasons for failure.

3 Lifestyle programme

Has the practice given help to the patient to self-evaluate their weekly calorie intake?

Do you believe that the patient understands how their food intake impacts on their obesity?

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Exercise Programme with regular input

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.

5 Psychological Interventions/ Cognitive behaviour therapy

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).

6 Drug intervention

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.

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NHS NUMBER: PATIENT NAME: D.O.B:

CLINICAL INFORMATION /MEDICAL HISTORY

7 Current Medication Please supply list of current medication

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Recent blood test results ( within 3 months)

Urea and electrolytes

Fasting plasma glucose

HbA1c (if diabetic)

Lipid profile

Liver Function

Thyroid function

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Medical history and co-morbidities

(Relevant clinical correspondence, specialist input to be included with request)

Diabetes

Cardiac pathology including angina, congestive heart failure, arrhythmias

Hypertension. (Recent Blood Pressure to be provided) BP: Date:

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

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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

NHS NUMBER: PATIENT NAME: D.O.B:

ADDITIONAL INFORMATION

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Additional information required to assess for Tier 3 WMP

Are there are any specific clinical contra-indications to the patient participating in the Tier 3 WMP that you are aware of?

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

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