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Access Criteria – Tier 3 & Tier 4

Tier 3 – Adult Weight Management Programme

Patients can be referred to our service if they meet one or more of the following:

  • Has a BMI of over 35 * with obesity related co-morbidities, as set by individual ICB, and have failed to lose weight and maintain weight reduction within Tier 1 and Tier 2, despite engagement and compliance OR
  • Has a BMI of over 40 * without specified co-morbidities, and only after failure of Tier 1 and Tier 2 services, despite engagement and compliance. OR
  • Has a BMI of over 50 [Tier 2 not required. However recommended]

Patients must also:

  • be aged 18 years or above
  • be motivated to make lifestyle changes and commit to the programme
  • be appropriate for a Tier 3 service

In some cases this is also subject to assessment by the MDT even if meeting the above criteria to ensure our patients are on the appropriate support pathway.

Tier 4 – Adult Surgical Pathway

Patients can be referred to our service if they meet the below criteria:

  • Have received and completed intensive level (tier) 3 services and
  • have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 39.9 kg/m2 with a significant health condition that could be improved if they lost weight and in line with local commissioning criteria and
  • agree to the necessary long-term follow up after surgery

Patients must also be:

  • aged 18 years or above
  • motivated to make lifestyle changes and commit to the programme
  • be appropriate for a Tier 4 service

*Consider referral in Tier 3 or Tier 4 for people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background using a lower BMI threshold (reduced by 2.5 kg/m2) than listed above to account for the fact that these groups are prone to central adiposity and their cardiometabolic risk occurs at a lower BMI.

Examples of obesity-related health conditions:

  • cardiovascular disease
  • hypertension / idiopathic intracranial hypertension
  • obstructive sleep apnoea
  • type 2 diabetes
  • Osteoarthritis

These examples are based on the evidence identified but the list is not exhaustive. Some obesity-related comorbidities may require exceptional funding approval prior to acceptance.

Expediting patients to Tier 4

In cases where mortality may be impacted and significant/rapid weight loss is required (i.e pre-cancerous or active cancer awaiting surgery, stage 4 or 5 renal patient or patients awaiting transplant surgery) this should be highlighted on the referral for our clinical team to review appropriately. An exceptional funding application should be submitted by the GP to the ICB and approval enclosed with referral to our service.

What contraindications are there for referral into the Tier 3 service?

  • Active untreated mental health condition
  • Presentation of active risk concerns that require assessment/stabilisation
  • Active substance use disorder
  • Active eating disorder. For individuals who have had an active eating disorder in the past 12 months, we recommend advice is sought from the treating clinician regarding time period recommended prior to engaging in weight loss intervention.
  • Patients that have had private bariatric procedures and are being referred for routine follow up, not meeting the access criteria at the time of surgical intervention. Patients should ensure they arrange follow-up care from their private surgery provider. Primary care practitioners should consider using support from the BOMSS GP Hub

 What contraindications are there for referral into the Tier 4 service?

  • Active untreated mental health condition
  • Presentation of active risk concerns that require assessment/stabilisation
  • Engagement in self-harm behaviour in the past 12 months
  • Inpatient mental health admission in the past 12 months
  • Substance use disorder in the past 12 months
  • Eating disorder in the past 12 months
  • Patients that have had private bariatric procedures and are being referred for routine revisional surgery (i.e weight regain)

How long do we follow up patients after surgery?

NHS patients are followed up within our service for two years after surgery and then discharged back to the care of their GP. Patients should then be managed within primary care, however patients can be re-referred to us if there are concerns of surgical complications.

GP Responsibilities – Postoperative care

We follow up patients for two years after surgery. After two years we will discharge a patient back to your care if clinically appropriate. It is important to note the GP responsibilities relating to postoperative care before referring a patient for weight loss surgery.

Following weight loss surgery, patients are at a greater risk of nutritional deficiencies and patients that are no longer under the care of our bariatric unit will require annual blood monitoring and lifelong nutritional supplementation.

Upon discharge, we supply a patients GP with an information sheet relating to postoperative medication and supplements. Also, you can visit the BOMSS GP Hub for more information on how to manage this cohort of patients or contact us directly via the Advice and Guidance on e-RS.

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