Tier 3 & 4 Weight Management Service - BNSSG

Overview

****12/06/24 - See updates about new and existing referrals below *****

New Referrals

The NBT Tier 3/4 weight management service is still closed to new referrals.

Existing Referrals 

BNSSG ICB have now entered into a contract with Oviva, a company that offers a remote Tier 3 service - https://oviva.com/uk/en/specialist-weight-management/ It is one of the organisations recommended by NICE.

In excess of 350 patients have elected to transfer from NBT to Oviva. Oviva are currently preparing to contact these patients to start them on the pathway.

Given the length of time since the original referral may have been made to NBT, Oviva will likely be contacting practices in order to secure any updated relevant patient information over the next month. Practices are requested to support this exercise in order to allow patient treatment to commence as soon as possible.

Patients currently on the NBT T3 waiting list were offered the option to move across to Oviva via text message to be treated sooner – ONLY patients who chose to move will be transferred.

A further text message will be sent out to patients in the coming weeks inviting them again to consider moving across to have their support from Oviva. As before this will be with a few provisos:

• This Oviva service will be aimed solely at patients on the medical pathway, not the surgical pathway – i.e. if the patient wants to access bariatric surgery, this is not an option for them.
• Support is provided via an App or on the telephone by Oviva so patients will need access to a device to engage with Oviva or use of a telephone.
• If patients consult with their GP about Oviva, we ask that you are supportive of this choice. Please note that patients need to respond to the text message confirming their desire to move to Oviva to start that process.

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The BNSSG Weight Assessment and Management Service (WAMS) is a multi - disciplinary service for people with severe or complex obesity and is based at Southmead Hospital, Bristol.

WAMS is a specialist service with the goal of improving the health and well-being of morbidly obese adults through promoting life-long behaviour change. It is not simply an assessment for bariatric surgery and those referred for consideration of surgery should understand that in most cases this will not be appropriate without some preparation, focussing on regulating eating, portion sizes and emotional regulation. Generally this takes 6-12 months in WAMS.

The WAMS team are supportive and non-judgemental and will take into account the individual's circumstances. The team includes:

• Consultant Physicians

• Counselling/Clinical Psychologists

• Assistant Psychologists

• Dietitians

• Programme co-ordinators

Referral Criteria

There is a Weight Management Service (Tiers 3 and 4 - including Support and Obesity related Surgery) Criteria Based Access Policy which applies to all BNSSG patients.

In summary:

Patients must have a BMI of 40 or over (or 35 or over if co-morbidities)

Patients much have engaged with community weight services over a 2 year period (please provides dates they attended as evidence) and attended a Tier 2 Weight management service unless BMI is 50 or greater*

(Please see full policy for further information and exclusions).

*Patients with BMI of 50 or over can be referred directly without evidence of compliance with Tier 2 Weight Management.

GP information leaflet

Please also see section below for further clarification regarding funding requirements for gastric bands.

What to do before referral

Patients must meet referral criteria

Before referring patients must fulfil the criteria within the CBA policy (see link above).

Please note that patients who have had previous weight loss surgery will not meet criteria unless there are exceptional  circumstances and individual funding will need to be obtained for these patients. Please see further details in Gastric Band section below.

Mandatory blood test results must be provided:

Full Blood Count                                     B12 and Folate

Urea and Electrolytes                             Thyroid Function Tests (TSH)

Liver Function Tests and FIB-4              Fasting Lipid Profile

Calcium and Vitamin D                            HbA1c

Fasting glucose (this is a new requirement)

Provide patients with written information

The attached patient leaflet  should be given to patients if considering referral.

After referral the What can you do whilst you wait for your weight management appointment? leaflet may be helpful.

Referral

****Update 12/06/24*****Service currently closed to new referrals

Referrals should be made using the standard Tier 3 proforma which can then be submitted via e-Referral.

The service can be found on e-RS via:

• Priority: Routine
• Speciality: GI & Liver,
• Clinic type: Upper GI including Dyspepsia,
• Weight Management RAS Service – Southmead

GLP-1 receptor agonists

****Update 12/06/24*****Service currently closed to new referrals

Liraglutide (Saxenda) and Semaglutide (Wegovy) are licensed for use in certain patients with a BMI >35 and Non-diabetic hyperglycaemia, and NICE have given recommendations on its use under NICE TA664and NICE TA875

A locally agreed pathway to access this treatment is being put in place that allows prescribing in secondary care weight management clinic, but only if the current criteria for a weight management referral are met. Suitable patients will be supported and prescribed treatment for up to 2 years. 

Patients who do not meet the criteria will not be able to access this treatment on the NHS at this time. Please see the Obesity page in the BNSSG formulary for further details.

Patients with diabetes who meet criteria for prescribing of Liraglutide or other GLP-1 receptor agonists will continue to be able to access these medications as normal. Please see the Diabetes Mellitus page in the BNSSG formulary for further details.

Gastric Bands

Referral for new patients - ****Update 02/05/24*****Service currently closed to new referrals

Referral for gastric band surgery is only accessible via the tier 3 weight management service as detailed above. Patients must meet the criteria stated in the funding policy or otherwise will not be accepted by the service unless exceptional funding has been obtained.

Patients who have undergone previous weight loss surgery

Patients who have previously had surgery (private or NHS) and are not currently receiving follow up cannot be referred without securing individual funding first.

In addition, please see the following advice about appropriate referrals from the exceptional funding team.

Patients who have previously had a Self-Funded gastric band

Patients who have self-funded a gastric band procedure either in the UK or abroad are responsible for all elective follow up and this is not funded by the NHS. However, if a patient has an acute complication (i.e. extensive pain/vomiting) then they will need to be admitted for urgent assessment and management. This may include “deflating” their band. Refilling a band after the acute episode is not covered by the NHS. A band may be removed during an acute treatment episode if perhaps it has slipped dangerously and as long as it is part of the urgent care, but replacing the band would not be funded.

Patients who have previously had a NHS funded gastric band

Patients receiving treatment on the NHS are able to be seen for 2 years post-surgery to optimise any band fills etc. After 2 years, NHS care isn’t routinely funded except in an acute episode as described above – again any refilling or the band would not be routinely funded by the NHS.

Post Bariatric Surgery Monitoring and Complications

See the Post Bariatric Surgery Monitoring page for advice and tips for patients post bariatric surgery and how to manage complications.

Patients with non- acute abdominal Symptoms who have had bariatric surgery

If a patient presents with non- acute abdominal symptoms following bariatric surgery, then they should be investigated and managed in primary care initially (see Post Bariatric Surgery Monitoring ).  You can also request GI Advice & Guidance and refer if appropriate.

Exceptional Funding

The exceptional funding team (EFR) do occasionally get requests to deflate/remove bands in patients who have had either NHS (more than 2 years following surgery) or Self-Funded surgery. This is not funded and can only be considered if there is exceptionality that is agreed by the funding team.

If further clarification regarding referrals is needed please contact the funding team via email at bnssg.efr@nhs.net

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.