Referral Form for the BNSSG Tier 3 Multi-Disciplinary Weight Management Service (BNSSG Patients)          Non Face to Face Remote Service ONLY 

Multi-Disciplinary Weight Management Service
This service provides assessment and management of BNSSG patients with severe or complex obesity. It offers a specialist multi-disciplinary weight management assessment (including psychological, dietitian and medical/surgical support), followed by a 6-12 month programme of care comprising of group and individual treatment sessions with the following key aims:
•	To encourage long term behaviour change through promoting healthy eating, physical activity and recognising the psychological barriers to unhealthy relationships with food; 
•	To prevent / reduce / improve the management of any co-morbidities associated with severe obesity together with costs associated with these;
•	Where appropriate, refer patients for Tier 4 surgical assessment and prepare these patients by supporting them to understand the risks of the surgery, the need for behaviour change pre and post-operatively and to assist in the decision making process.
•	Patients who have undergone previous weight loss surgery will not be seen in T3 without securing individual funding first.

To Note:
Please fill in all sections of the referral form along with any other information you think is relevant to this patient’s case. Please could you ensure that the relevant blood tests in section 2b have been completed and the results (within the last 12 months) attached. The referral will not be accepted unless the referral form is complete and all of the blood tests have been completed.

Criteria for Referral to the BNSSG Tier 3 Multi-Disciplinary Weight Management Service
The Criteria Based Assess policy for this service is available on the relevant CCG website.
In order to refer a patient to this service they must be in one of the following three categories* ()
BMI ≥40¹ without co-morbidities and patient has actively/persistently engaged with losing weight over the last 2 years with a structured tier 2 or equivalent programme. 		
BMI ≥35¹ with co-morbidities (established cardiovascular disease, type 2 diabetes, hypertension, obstructive sleep apnoea, NASH or idiopathic intracranial hypertension) and patient has actively/persistently engaged with losing weight over the last 2 years with a structured tier 2 or equivalent programme.		
BMI ≥50¹		
¹a tolerance of BMI 2.5 on each criteria above for at risk groups: black African, Caribbean and South Asian origin.

Continued on next page

Status & entry criteria*	()
In order for the patient to be successfully referred to the BNSSG Tier 3 Multi-Disciplinary Weight Management service the following questions must all be answered positively:			
Patient does not have significant mental health disorder that would prevent engagement with the service.		
Patient does not have active binge eating disorder or bulimia nervosa.		
Patient does not have an active history of substance/alcohol misuse or dependence.		
Patient has not been referred and then left the service within the last 12 months.		
Patient is not pregnant.		
Patient in agreement with referral to weight management and understand they must demonstrate a long-term commitment to making lifestyle changes (dietary and activity).		
Patient is aware that this service is a medical only pathway and not suitable for those may or would consider bariatric surgery.		
Patient is aware that this service is a remote and can be only accessed via an app or over the telephone.		

Part 1 – Patient Information 

Name	Full Name 	
Address	Home Full Address (stacked) 	
Date of Birth	Date of Birth 	
Telephone	Patient Home Telephone 	
Mobile	Patient Mobile Telephone 	
Email	Patient E-mail Address 	
NHS Number	NHS Number 	
GP Name	Usual GP Full Name 	
GP Address	Organisation Full Address (stacked) 	

As recorded within the last 12 months
Weight (kg)	Weight 
	Height (m)	Height 
	
BMI (kg/m2)	BMI 
	BP (mmHg)	Blood Pressure 

Part 2a: Medical Assessment
Co-morbidities
	Yes	No	Year diagnosed	
Type 2 Diabetes			     	
Hypertension			     	
Obstructive Sleep Apnoea			     	
Heart Disease			     	
NASH (non alcoholic steatohepatitis)			     	
Idiopathic intracranial hypertension			     	

Other significant medical or mental health history – or attach EMIS print out
Medical Diagnosis	Current Treatment	

Please see end of form.

	

Medications – please write below or attach current list
Medication	Dose	Medication	Dose	Medication	Dose	
Medication 

Part 2b: Investigations/Blood Test Results (taken within the last 12 months)
The following blood test results should be attached to the referral (Profile on ICE):

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 
Single Code Entry: FBC - full blood count  
Single Code Entry: Urea and electrolytes level  
Single Code Entry: Liver function test  
Single Code Entry: FIB-4 (Fibrosis-4) index score  
Single Code Entry: Thyroid function test  
Single Code Entry: Fasting lipid profile  
Single Code Entry: HbA1c - Hemoglobin A1c level

Has patient had bariatric surgery before?

	Yes	No		
				
Is patient keen on weight loss surgery, should this be an appropriate option for them?	Yes	No	Unsure	

Name of Referring Doctor				Signature			Date	
Free Text Prompt 

	Free Text Prompt 	Short date letter merged 	

Allergies 
Consultations 
Problems 
Values and Investigations  
Please submit this via e-referral system.