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Tier 4 – Weight Loss Surgery

The information on this page has been produced to provide useful information to those either currently in our service or for those who might want to know more about what we offer.

What is a Tier 4 service?

The main aim of a Tier 4 specialised obesity service is to achieve a significant weight reduction and improve obesity-related medical conditions. A Tier 4 service is focused (but not limited to) on a surgical pathway for patients that have been through Tiers 1 to 3 but require further intervention to achieve and maintain significant weight loss. The Tier 4 pathway includes an MDT assessment to determine suitability and eligibility for a surgical intervention. If deemed suitable for surgery you would then see a surgeon to discuss possible and suitable surgical interventions. Weight loss surgery is recommended as a treatment option for people diagnosed with obesity related medical conditions and offered surgery based upon the criteria listed below.

Am I eligible for Tier 4?

You can be referred to our service if your Body Mass Index (BMI) is increased to a certain level and you also have health problems related to your weight. We support patients that:

  • have received and completed a Tier 3 weight management service and
  • have a BMI of 40 or more (or a BMI over 35 with other medical risks) and
  • agree to the necessary long-term follow up after surgery

Patients must also be:

  • aged 18 years or above

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

Policies will be reviewed in light of new evidence or new national guidance.

How can I be referred to the service?

You cannot self-refer to our service. You can be referred by:

  • Your GP (preferred option due to access to wider medical and weight history)

Your specialty consultant can also recommend a referral via your GP.

You will need to meet the access criteria listed above.

Which clinicians will I see?

Our Tier 4 service provides expert assessment and support from a variety of clinicians including:

  • Specialist nurses
  • Specialist dietitians
  • Clinical psychologist
  • Consultant Anaesthetist
  • Consultant Surgeon
  • Consultant Physician (where appropriate)

FAQs

In this section

You will receive an appointment letter for an initial ‘opt-in’ appointment with one of our clinicians or an MDT (multi-disciplinary team) assessment, depending whether you are referred following Tier 3 at this Hospital or another provider. This assessment is to determine safety and eligibility for weight loss surgery. We are liberal in our criteria for weight loss surgery but cannot guarantee that you will be suitable. The MDT decision around approval for weight loss surgery remains final and cannot be changed, a decision is agreed in the best interests of the patient. Please note that until a time where you are assessed by our MDT, your primary care needs remain with your GP.

Yes, dependant on your BMI you will be expected to commit to a 6 or 12 month weight management programme (Tier 3). We normally recommend that patients aim to lose at least 5% of their weight recorded at their first visit. If you are unable to meet your weight loss target, your progress into Tier 4 could be delayed or declined.

Weight loss surgery is an elective procedure that has life-changing effects and therefore requires extensive assessments to determine suitability and safety. Every patient has a unique pathway towards surgery and time frames may differ from one patient to another. Patients do not always get a date for surgery in the same order that they are booked in clinic as some patients may require more investigations or expertise of particular surgeons. It is not possible to tell you exactly how long you will have to wait for your surgery.

You will need to complete assessments from our multidisciplinary team, consisting of a specialist dietitian, nurse, psychological professional and consultant anaesthetist. The MDT will then meet to discuss your progress and decide whether weight loss surgery is suitable and safe for you. The MDT will discuss and consider the following:

  • Lifestyle changes demonstrated
  • Weight loss achieved
  • Stopped smoking (if applicable)
  • Whether you are prepared for the effects of surgery
  • Whether you are as fit as possible for surgery

The MDT will then communicate the recommendations with you. In some instances, further tests or support may be required before progressing to surgery but this will be discussed with you. If the MDT are happy with your progress and agree that weight loss surgery is right for you, you will then see a surgeon to make an informed decision as to which operation you would like to have.

Please click here for more information. Risks relating to weight loss surgery will be discussed with you prior to your surgery and listed in the consent form.

These operations are usually completed using a “laparoscopic” (keyhole) technique under general anaesthetic. All weight loss surgeries in our institute are done with a keyhole technique, either laparoscopic or robotic, both of which has similar outcomes. Your surgery can take place with either of the two techniques, both of which are minimally invasive.

For NHS patients who have had surgery with us, you will receive follow up care for 24 months. An approximate period of follow up after surgery would be at 6 weeks, 12 weeks, 6 months, 12 months and 24 months after weight loss surgery, however this can be tailored according to your clinical needs. Following your final follow up appointment, you will be discharged back to the care of your GP with advice on how to support your management going forward. GPs can take our advice pertaining to your management or refer back for potential complications surrounding your surgery, if the need arises.

We cannot guarantee that your surgery will go ahead on the day due to a variety of factors that are out of our control. Examples of reasons why your surgery may not go ahead on the day include; excessive acute admissions into the Trust, another surgery on the same day may exceed the original booking time or there is a medical reason to postpone your surgery that requires further investigations or optimisation. Although these are uncommon, they may occur.

We cannot guarantee that the same surgeon you saw in clinic will perform your surgery on the day. We do our best to ensure that you have the procedure carried out by the same surgeon. In the vast majority of cases the same surgeon you saw in clinic will perform your surgery, however in rare occasions it may be a different surgeon and this is mentioned on the consent form. All of our surgeons are highly qualified with vast bariatric experience.

You may be discharged and removed from the waiting list unless there is a good reason for you to cancel on the day. We do understand that you may change your mind on having surgery or there may be a change in circumstances, we kindly ask that you contact our waiting list team to cancel your surgery at least 14 days in advance as this will allow us time to offer this slot to another patient.