Pathway for People Using Weight Reduction Services

Transcription

1 NHS DERBYSHIRE COUNTY Pathway for People Using Weight Reduction Services Production date: November 2009 Reviewed and Updated: February 2011 Key Messages: This is a pathway for patients referred to the Weight Reduction Services Page 1 of 30

2 Contents Page Executive Summary 3 Overview of weight reduction services 4 Assessment of risk factors and other conditions 5 Assessing motivation to change 6 Which pathway for which patient group? 9 Pathway for the management of the overweight 10 Clinical Pathway for the Management of Obesity and Morbid Obesity 11 Continuation of the Pathway for the Management of Obesity and 12 Morbid Obesity Supporting information for use with the Clinical Care Pathway 13 Weight Reduction Programmes available and what they offer 15 Monitoring of outcomes/monitoring of weight in Primary Care 17 Obesity and pregnancy 18 Pharmacotherapy 19 Waist Circumference 20 Appendix 1 Weight Reduction Services Referral Form 21 Appendix 2 Information leaflet for the unmotivated 23 Appendix 3 Information leaflet maintaining weight loss 24 Appendix 4 Ordering and download information for patient leaflets 25 Appendix 5 Resource material list for information booklets 26 Appendix 6 List of leisure providers and contact information 27 Appendix 7 Readiness to Change Tool 29 Page 2 of 30

3 Executive Summary General Practice plays an important role in overseeing the patient journey through the obesity pathway, even if they are not directly involved in delivering weight reduction services. This pathway places the General Practice at the centre of a range of services that are offered. The GP practice has an important role in the co-ordination, monitoring of effectiveness of approaches and being able to accelerate the patient through the pathway, as appropriate. It is recommended that services be targeted towards overweight/obese patients aged 16 and over, with either significant co-morbidities or increased CVD risk. Overweight/obese patients aged 16 and over Type 2 Diabetes with significant co-morbidities. Dyslipidaemia Obstructive Sleep Apnoea Hypertension Polycystic Ovarian Syndrome Increased risk of CVD. Increased Cardiovascular Disease (CVD) Risk (Free NHS Health Check) The pathway will direct referrals to appropriate services on BMI trigger points, these trigger points will be:- BMI =28 with significant co-morbidities or BMI =30 BMI =35 to 39.9 BMI with significant co-morbidities BMI =40 BMI =50, or =45 with significant co-morbidities Bariatric Surgery Bariatric Surgery will only be considered for those patient s with a BMI =50, or =45 with *significant co-morbidities. This is in accordance with the East Midlands Specialised Commissioning Group: Commissioning Policy for Access to Bariatric Surgery. Significant co-morbidities could include: Established cardiovascular disease Osteoarthritis 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 Polycystic Ovarian Syndrome Metabolic Syndrome Copies of this document are available to view or download online at: erral_guidelines_updated.pdf Page 3 of 30

4 Overview of adult weight reduction provision in Derbyshire County BMI Prevention Tier 1 BMI = 25 Early Intervention Tier 1 BMI = 28 with comorbidities BMI = 30 Tier 2 Services BMI = 35 with related and significant co-morbidities BMI = 40 Tier 3 Services BMI = 45 with related comorbidities BMI = 50 Tier 4 Services WEIGHT Some of the services available in Derbyshire promoting a healthy lifestyle: 5 A Day promotion Cooking groups Jog Derbyshire Walking groups Leisure/health centre based activities Active Derbyshire Information on lifestyle provided by the patients Practice, in the form of a brief consultation / provision of relevant information. Signposting to relevant services available, this may include walking groups, leisure centre based activities, local community based groups. Commercial programmes not invested in by NHS Derbyshire County. Areas for Development: Increase the skill base of leisure centre staff to extend the range of services available. The HUB is a lifestyle intervention programme supporting behaviour change in increasing physical activity and improving nutrition through: WaistWise: 12 week course. Physical Activity component. Separate groups for men and women. Self Management Option: Supported through websites outlined in the guidance or relevant health education booklets provided to the patient. Health Referral Scheme: Currently delivered as a supporting physical activity programme across the pathway. Areas for Development: Integrate HUB providers to deliver a seamless service. All providers have to meet the standards set out by NHS Derbyshire County for the provision of a Tier 2 weight reduction service. Tier 3 Weight Reduction Service: Patients must fit the service referral criteria outlined in the clinical care pathway to access this service. Patients must have completed a Tier 2 programme in order to be eligible for referral to this service (Unless they have a BMI = 45 with co-morbidities or BMI >50). The service provides intensive weight management programmes tailored to meet individual needs, delivered by a multidisciplinary team with the following specialist inputs: Psychological Dietetics and Nutrition Physical Activity Occupational Therapy Supported by key link workers. For those patients assessed as appropriate referrals for bariatric surgery the Tier 3 Weight Reduction Service will implement a pre surgery lifestyle programme, which the patient must comply with in order to be referred for surgical intervention. The Tier 3 Weight Reduction Service will then manage the patient post bariatric surgery. Bariatric Surgery provided the patient has been pre-assessed by the Tier 3 Weight Reduction Service and undergone the presurgical lifestyle intervention. Bariatric teams will return any referrals that do not meet the criteria or pre-requisites. Health Referral Scheme: Delivered across the pathway as a supporting physical activity programme, offering tailored physical activity programmes, support and advice. As part of the HUB the offer includes the provision of 6 physical activity options - walking, gym, swimming, group exercise (inc. low impact) + 2 others. Workforce Development: A range of training is available for staff working within Primary Care, this includes training in assessing patients motivation, thus aiding staff in using the referral pathway to full effect. There will also be a training plan developed for staff working with vulnerable people and hard to reach user groups (e.g. learning disability support workers, mental health support workers, prison staff). Page 4 of 30

5 Assessment The clinical care pathway for the management of obesity and morbid obesity requires the referrer to assess other conditions and risk factors connected with obesity, these are outlined below. This will aid the healthcare professional to refer patients to the most appropriate weight reduction intervention. Assessment of Risk Factors: Dietary factors Physical activity levels (Ideally assessed through use of the General Practice Physical Activity Questionnaire GPPAQ) Risk Factors that may be touched upon during a practice based consultation: Environmental and social factors Familial tendencies Other risk factors for obesity that cannot be assessed in a Primary Care setting: Psychological factors Genetic and Neuroendocrine factors Assessment of other conditions: Established cardiovascular disease Osteoarthritis 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 Polycystic Ovarian Syndrome Metabolic Syndrome Raising the issue of weight Research undertaken for the Choosing Health consultation (2004) found that some healthcare professionals including GP s, were uncomfortable about raising the issue of weight with patients. To help support healthcare professionals working in primary care, a readiness to change tool and brief intervention training module has been developed by NHS Derbyshire County to work in conjunction with this process. For further information please contact Steve Pintus at: steve.pintus@derbyshirecountypct.nhs.uk The Department of Health has also developed a tool designed to help healthcare professionals when in a consultation with an overweight or obese patient, this can be downloaded at the following web address: _ pdf Alternatively it can be ordered free of charge by calling: quoting the order code: Page 5 of 30

6 Assess Motivation to Change It is essential that patients are only referred to services if they have demonstrated a clear motivation to change. Training in how to assess motivation to change will be made available to all practices. This training will aid in the use of the tool below, designed by Derbyshire Community Health Services, Health Psychology Department, to be used in conjunction with the weight reduction referral pathway, in order to help ensure that only appropriately motivated patients are referred into weight reduction services. A spare copy of this tool is available as appendix 7 for ease of use. FIVE STEPS TO ASSESSING READINESS TO LOSE WEIGHT This guidance is to be used together with the explanatory notes. STEP 1: How to begin Begin by saying something like: I m interested in finding out how you feel about trying to lose weight. Can you help me by answering a few simple questions? Ask targeted, open questions: Some suggestions are How do you feel at the moment about losing weight?, How would life be different if you were to lose weight? What changes, if any, are you thinking of making regarding your weight? STEP 2: Use a rating scale to measure readiness For example: How ready do you feel to make changes regarding your weight at the moment? On a scale of 0 to 10, where 0 is not ready at all, and 10 is totally ready, what score would you give yourself? Not Ready Totally Ready Follow up, as necessary, with questions such as: a. What puts you at a_ (chosen number) and not a_ (lower number)? b. What would it take to move you from a _ (chosen number) to a _ (higher number)? A low score of 3 or less indicates that the patient may not be ready to make changes at the moment. It may not be the right time to discuss treatment options and it may be best just to summarise your discussion and make the patient aware of future support. If the patient scores 4 or higher, GO TO STEP 3. STEP 3: Use a rating scale to measure importance and confidence For example: On a scale of 0 to 10, with 0 being not at all important, and 10 being extremely important, how important is it for you to lose weight at the moment? Not at all Important Very Important Also on a scale of 0 to 10, with 0 being not at all confident, and 10 being extremely confident, how confident do you feel about being able to lose weight at the moment? Not at all Confident Very Confident Page 6 of 30

7 Use appropriate follow-up questions. If the patient has a low rating on importance, target questions on what, if anything, could help to make losing weight a higher priority. If the patient has a low rating on confidence, target questions on what, if anything, could help them feel more confident about losing weight. Plan with the patient how to increase importance and/or confidence. Then, when appropriate, ask the patient to rate again. Low scores of 3 or less on both scales indicate that the patient may not be ready to make changes at the moment. It may be best just to summarise your discussion and make the patient aware of future support. If ratings are in the mid range (4-6), explore further by using a pros & cons list see STEP 4. If ratings are 7 or more, go to STEP 5. STEP 4: Use a pros and cons list Ask patients to list the pros and cons or advantages and disadvantages of losing weight. This can help explore ambivalence (mixed feelings) about change. STEP 5: Check barriers to change Before discussing a referral, check whether there are any significant barriers which may prevent the patient from making good use of the weight reduction options available, especially at the moment. Check: current stressors/time available/lack of knowledge/support from and views of others (e.g. family)/ psychological issues that may prevent weight loss. Plan with the patient how to manage or overcome barriers, as appropriate. ASSESSING READINESS TO LOSE WEIGHT Explanatory Notes Introduction It is important to assess whether an individual feels ready to engage in a weight reduction programme, in order that resources are used most effectively and that those patients who are referred are the ones who are most likely to make use of what s on offer. Talking about weight can be a sensitive issue, and the use of a collaborative, patient-centred approach is recommended. The establishment of good rapport forms the basis of the assessment and affects its quality. Assessing readiness to change can be a difficult task because motivation can fluctuate over time and across different behaviours (for example a patient may feel quite motivated to eat less fat, but less motivated to exercise more). It is important for us to recognise that levels of motivation can be influenced by the conversations about behaviour change that we have with our patients. Offering support, encouragement, and follow up where appropriate, can enhance motivation to lose weight. The questions overleaf are suggestions for guiding a conversation with a patient around weight loss. They are designed to help answer the question: does this person want to lose weight at this moment in time? and, if they do, is it appropriate to make a referral to a weight reduction programme?. Getting Started/Raising the Issue Before asking the questions overleaf, it is important to ask yourself the following: Are you fully aware of the weight reduction options available locally? Have you asked the patient s permission to discuss weight loss options? Does the patient understand the benefits of weight loss and the risks of obesity? Has the patient expressed an interest in losing weight? If there is no interest expressed in losing weight at this stage, the patient is unlikely to be receptive to further questions. It may be more appropriate to give information and the opportunity to return. Page 7 of 30

8 Using a numerical rating scale This can help to gauge patients interest in losing weight on a scale. It can be used either verbally, or by showing the patient, and asking them to mark a point on the scale. Higher scores indicate greater levels of readiness to change. Low scores (in the 0-3 range) indicate the patient is unlikely to be ready to make changes regarding losing weight at the moment. Mid range scores (in the 4-6 range) indicate the patient may feel ambivalent about change. Further exploration through the importance and confidence scales, and the use of a pros and cons list can help clarify readiness. High scores (7 or above) indicate the need to consider making a referral. Making a referral If, from your assessment, you feel that the patient has expressed a high level of motivation to lose weight, and there are no significant barriers to change, discuss the options available, and consider making a referral. A decision by a patient to think about the options, and not necessarily accept the referral to a weight reduction programme immediately, can be a useful outcome. Giving information regarding the risks of obesity, benefits of weight loss, and treatment options available, may be enough at this stage. Helping patients think about change via a constructive discussion, however brief, can enhance motivation. Offering support and the opportunity for follow up, leaves the door open for future change. Not Ready to Change Those individuals who are assessed for motivation and determined to be unwilling or unable at present, to address the issue of their weight should be given some relevant information to consider (appendix 2) and then booked in for a follow-up appointment 6 months later (this appointment could be linked into a follow-up appointment for another condition, e.g. blood pressure check for hypertensive patients). Page 8 of 30

9 Which pathway for which patient group? Turn to: Pathway A1 page 10 For patients presenting with a BMI =25 but not classed as obese. Pathway A2 page 11 For patients with a BMI =30 or =28 with co-morbidities. Pathway A3 page 12 For patients presenting with BMI = 40 who have completed a Tier 2 programme without success and patients with a BMI = 45 with co-morbidities or = 50 who can be referred directly to the Tier 3 Weight Reduction Service. Adult Obesity Referral Pathway Notes for Referrers Access to the referral pathway is through General Practice where the patient should be assessed as ready to make behaviour change and willing to engage with a weight reduction programme before being referred into any of the services available. Ideally patients will be assessed at 12, 24 and 52 weeks. The services delivering the weight reduction programmes will feedback results to General Practice, for monitoring and auditing of patient progress. In some cases the service may not be able to recall the patient at the specified measurement point, therefore it is important that General Practice takes appropriate opportunities (see page 18) to record patient s weight. This will also enable General Practices to move the patient onto the next appropriate stage of the pathway. This will support any audit processed for validation of the success of different weight reduction programmes. This process will also be aided if General Practice staff ensure that they log all patients that are referred into a weight reduction programme by using the appropriate read code(s). Referral (using the referral form appendix 1) into any service on the pathway can be made by any member of Practice staff that is appropriate for assessing the patient s need. For complex cases this may require the referral to be made or managed (if pharmacotherapy is used in conjunction with any programme) by a General Practitioner or Nurse Practitioner. From April 2011, a new joint form will be used to refer patients to the Health Referral Scheme and WaistWise. Tier Three Weight Reduction Service referrals will remain through a standard referral letter from General Practice. Electronic referrals will be available by late Page 9 of 30

10 Pathway A1 Pathway for the Management of Overweight: Patient presents with any of the following: BMI =25 The page numbers in italics indicate the page in the guidance where further information can be found GP Practice BMI = 28 with related co-morbidities or relevant risk factors or BMI = 30 NO YES Continue patient journey through pathway A2 page 11 Assess motivation pages 6-8 Opportunistic reassessment of motivation level Printed information on further weight gain and health risks provided Page 24 NO Ready to Change YES Discussion with patient on issues around weight, nutrition, physical activity and lifestyle. This brief consultation may also include: Signposting for local services available. Relevant British Heart Foundation/Food Standards Agency or other appropriate information resources provided. Relevant website information provided for weight management e.g. Pages Not appropriate for referral. Patient monitored opportunistically Page 17 Page 10 of 30

11 Pathway A2 Clinical Pathway for the Management of Obesity and Morbid Obesity Patient presents with any of the following: BMI =28 with significant co-morbidities or BMI =30 For supporting information used in conjunction with this pathway please refer to pages 13 and 14 in this document. The page numbers in italics indicate the page within this document where further information can be found related to that issue. GP Practice Assessment of other conditions and risk factors. page 5 Assess motivation page 6 8 Appointment made for reassessme nt in 6 months page 8 Printed information on weight and associated health risks page 24 NO Ready to Change YES BMI =45 with co-morbidities, BMI =50 or BMI =40 and already completed a Tier 2 programme NO YES Follow pathway A3 on page 12 Discuss with patient weight management options available to them (pages 15 & 16) and refer to most appropriate Tier 2 weight reduction service option. 12 week review successful outcome = 5% loss of initial bodyweight. Collected by the intervention and reported back to the Practice to update patient record and monitor outcomes YES 24 week review successful outcome = 5% loss of initial bodyweight. Collected by the intervention and reported back to the Practice to update patient record and monitor outcomes NO Identify underlying reasons why the outcome was not achieved & appropriate action required prior to patient undertaking further attempts. Reaffirm motivation. 2nd & 3rd attempt; consider using pharmacotherapy in conjunction with the weight reduction programme. Page YES Information given on importance of maintenance in weight management. Patient followed up opportunistically as part of co-morbidity review. Page 25 YES Still motivated to change lifestyle? BMI = 35 With related comorbidities? NO NO after 3rd attempt. Signpost towards ongoing support groups in the area. YES Continue on patient journey through pathway A3 on page 12. NO Printed information on weight and page 24 health risk. Patient informed they can return for re-assessment when they feel ready to do so. Page 11 of 30

12 Pathway A3 Continuation of the: Clinical Pathway for the Management of Obesity and Morbid Obesity BMI = 35 With related co-morbidities. Has attended Tier 2 Service 3 times and failed to lose weight. YES NO Patient referred to appropriate Tier 2 weight reduction Programme pages Refer to the Tier 3 Weight Reduction Service Assessment by the Tier 3 Weight Reduction Service. Patient assessed as appropriate for acceptance by the Tier 3 Weight Reduction Service YES NO Patient referred back to Primary Care to be reassessed in 3 months Intensive programme tailored to meet individual patient needs. BMI = 40 Has attended and completed a Tier 2 Service without losing =5% of bodyweight, whilst being compliant with the Tier 2 Service. BMI = 45 with co-morbidities or BMI = 50 refer directly to the Tier 3 Weight Reduction Service. Patient assessed as appropriate for acceptance by the Tier 3 Weight Reduction Service YES NO Patient referred back to Primary Care to be reassessed in 3 months Patient is managed by the Tier 3 Weight Reduction Service. The Tier 3 Weight Reduction Service will implement an intensive lifestyle programme with the client, who will be followed-up for a maximum period of 24 months. If the patient meets bariatric surgery criteria and wishes to undergo surgical intervention, the Intermediary service will manage this process and implement a pre and post surgery lifestyle programme, which the patient must comply with. The patients General Practice will be expected to oversee any medication prescribed to aid weight loss, as the Tier 3 Weight Reduction Service will be a lifestyle based service only. Outcomes reported back to General Practice. The Tier 3 Weight Reduction Service will liaise with General Practice as much as is appropriate on a patient by patient basis. Reviewed at 12 and 24 weeks by the Tier 3 Weight Reduction Service for weight loss > 5%, progressing to a target weight loss = 10% for morbidly obese patients. Patient followed up periodically by the Tier 3 Weight Reduction Service. It is also important that the patients weight is reviewed periodically in practice see page 17. Page 12 of 30

13 Supporting Information and Read codes to be used with the Clinical Pathway for the Management of Obesity and Morbid Obesity When referring patients to weight reduction services please use the following read codes: Referral to a weight management programme: TPP (Systm One) XaJSu All other systems 8HHH Alternatively if the patient is offered a referral and declines this can also be recorded under the following read codes: TPP (Systm One) XaQUp All other systems 8IAM Baseline measurements for; Body Mass Index (for patients being referred to a weight reduction intervention) can be recorded using the following read codes; Body Mass Index: All systems; 22k.. The patient must be assessed as ready to undertake lifestyle change and be motivated to participate with the weight reduction services specified within the Derbyshire County Obesity Referral Pathway. Referral to the Tier 2 weight reduction service listed on the adult obesity referral pathway must be done so using the Derbyshire Health Referral and WaistWise Referral Form (Appendix 1). Referral to Tier 3 weight reduction services must be made by standard letter referral and include all relevant information. It is important to discuss with the patient the weight reduction options available to them and what each programme entails, in order to gauge and agree a programme suitable for the individual. An individual can pass through the pathway a maximum of three times, including use of pharmacotherapy in conjunction with the weight reduction programmes. Pharmacotherapy must be used in conjunction with a lifestyle intervention. If after three attempts the patient has failed to lose = 5% of initial bodyweight, their motivation should be reassessed and reasons for failed attempts should be explored. If the patient is deemed as willing and able to undertake lifestyle change at this point a referral to the Tier 3 Weight Reduction Service should be considered, if they have a BMI = 35 with related comorbidities, if they do not, advice on self management should be issued. Patients with a BMI = 35 with co-morbidities, should only be considered for the Tier 3 Weight Reduction Service, if they meet the following criteria; Have attended Tier 2 services on 3 separate occasions and failed to meet the recognised weight loss target of 5% on every occasion, have attended more than 75% of the content of the Tier 2 service(s) they have undertaken, are assessed as ready and motivated to change behaviour, have complex comorbidities that would benefit from specialist input. Any individual who engages with a weight reduction programme and then drops out before completing the full programme, should firstly be followed up by that programme, to investigate the reasons why they have dropped out. Once the patient has been through a weight reduction service and successfully lost =5% of their bodyweight at 12 weeks, they should be recalled a further 12 weeks (24 weeks from baseline) later to monitor their progress. Their weight should then be monitored Page 13 of 30

14 opportunistically. Ideally this should be at least once every 52 weeks to monitor their progress and assess the long term effectiveness of the weight reduction services commissioned by NHS Derbyshire County. Patients with a BMI = 40 may only be referred to the Tier 3 Weight Reduction Service, if they have completed a Tier 2 weight reduction programme and failed to lose >5% of their initial bodyweight. (Any patient with a BMI = 50 or = 45 with significant co-morbidities* should be referred directly to the Tier 3 Weight Reduction Service.) *Significant co-morbidities could include: Established cardiovascular disease Osteoarthritis 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 Polycystic Ovarian Syndrome Metabolic Syndrome Page 14 of 30

15 WEIGHT REDUCTION SERVICE OPTIONS Once the patient is assessed as ready to participate in a weight reduction service they have the following options available to them; Tier 2 Services Through the Healthy Lifestyle HUBs Central Administration Team (CAT) patients are placed into the most appropriate programme based on the related clinical outcomes and personal goals: Health Referral Programme Patients are referred to increase their levels of physical activity, to be used in conjunction with the other programme for nutrition/lifestyle input. The Health Referral programme is a physical activity based intervention, which will be delivered primarily in local leisure facilities, but will vary dependent on local authority areas across the County. The scheme aims to offer a range of exercise choices e.g. gym based exercise, group exercise, swimming, chair based exercise. The patient will be advised by a fully qualified exercise referral instructor and exercise will be tailored to meet the needs of the individual. Health Referral is the umbrella name for the localised schemes: Be Active Amber Valley and Erewash areas New to Exercise South Derbyshire area Health Referral High Peak area Active Derbyshire Dales Derbyshire Dales area Bolsover Wellness Bolsover area Active Life Chesterfield area Health Referral Scheme North East Derbyshire For further information, please contact the Health Referral Administrator (Mon-Fridays office hours). Out of hours answer phone is available. WaistWise Programme (Delivered by the Derbyshire Health Promotion Service) Group based intervention consisting of 12 sessions, each session lasts a maximum of 2 hours and includes a tailored exercise session. Delivered in community venues across Derbyshire. Gender specific courses (separate courses for men and women) incorporating; healthy eating/drinking strategies, behaviour change/coping strategies, support and practical physical activity. Patients will also be referred into Health Referral from WaistWise to further increase physical activity. Due to the more intensive support offered by this programme it is anticipated that it will receive a somewhat more complex case mix of patients than other Tier 2 programmes. For further information please contact a member of the WaistWise team: Self Management If the patient wishes to manage their own weight, they should be supported to do so by being supplied with relevant information and by being invited for a follow-up appointment 12 weeks later to monitor their progress. At which point if no progress has been made in relation to weight loss, other options on the referral pathway can be explored. The Health Referral Scheme should also be recommended to the patient if they wish to self manage. There is a free website provided by NHS choices which can be utilised by those individuals wishing to self manage their weight loss, the web address for this is: There are many other websites available offering weight reduction support, we cannot vouch for the quality of these websites. If the patient wishes to access further information then ideal resources to pass on are; any of the British Heart Foundation booklets focusing on weight reduction and physical activity, and/or the healthy eating booklets from the Food Standards Agency (Some of the most appropriate material of this nature is listed in appendix 5). Page 15 of 30

16 Tier 3 Service Tier 3 Weight Reduction Service A specialist weight reduction service, accessible to patients who are morbidly obese and who have failed to lose weight through a Tier 2 service. This service offers an intensive tailored intervention, using an integrated approach based on psychological, dietetic and physical activity interventions. The service will also assess patients before bariatric surgery and support patients post-surgery. Therefore any patient who is eligible for and wishing to undergo surgical intervention should initially be referred to the Tier 3 Weight Reduction Service. Tier 4 Service Bariatric Surgery Patients referred for bariatric surgery should initially be referred to the Tier 3 Weight Reduction Service, where they will be assessed for their suitability for surgery and given a pre-surgery lifestyle programme to follow. The Tier 3 Weight Reduction Service will then, if appropriate, refer the patient for bariatric surgery in liaison with the patients General Practice. If surgery is deemed inappropriate the patient will be offered a range of alternative options by the Tier 3 Weight Reduction Service. The table below is the criteria for referral to bariatric surgery set by the East Midlands Specialised Commissioning Group. In order to manage this process, all patients who meet the criteria below and wish to undergo surgical intervention should be referred to the Tier 3 Weight Reduction Service. BMI Level Patients must have a BMI of 50 kg/m 2 & above or a BMI of 45 kg/m 2 to 50 kg/m 2 in the presence of a serious co-morbidity which may be amenable to treatment if obesity is modified by surgery Weight Management Has been receiving and complied with weight management support, both medical and psychological as required, in a specialised obesity hospital or a community based equivalent Age Previous treatments Patient wellbeing Follow-up Smoking 18 years and over Other options: Commercial organisations (not supported through the pathway) There is evidence that all appropriate and available nonsurgical measures, which may include commercially provided weight loss support programmes, have been adequately tried for a period of at least 6 months ideally 12 to 18 months, but has failed to maintain significant weight loss (i.e. =10%) There are no specific clinical or psychological contraindications to this type of surgery and the individual is generally fit for anaesthesia and surgery Patients must be committed to the need for follow-up by a doctor and long-term compliance with an altered lifestyle and dietary habit post-operatively Patients should not have smoked for at least 6 weeks prior to referral for surgery Page 16 of 30

17 Monitoring of Weight Loss Outcomes All baseline measurements will be recorded by the referrer (this predominantly will be a member of General Practice staff). The 12 week measurement point specified on the referral pathway will be undertaken by the programme delivering the intervention and feedback will be sent to the patients General Practice. The 24 week monitoring point will be undertaken by the service that delivered the intervention and outcomes reported to the patients General Practice. Monitoring of Weight in Primary Care Once a patient has successfully lost at least *5% of their initial bodyweight and maintained this for a minimum of 24 weeks through the Derbyshire Obesity Pathway, there is still the requirement to collect longer term data on weight maintenance. Therefore, ideally, all individuals undertaking any weight reduction intervention outlined in the pathway, which their General Practice is aware of, should have their weight monitored every 12 months. The patient does not have to be specifically called back into practice to have their weight monitored, if applicable it could be recorded opportunistically when the patient attends for any of the following, for example; Diabetes annual check-up Blood pressure checks for hypertensive patients Contraception Women attending routine check-ups who are taking the oral pill, or injection. It will be necessary to have some way of linking any opportunistic measurement recorded for a patients weight to the fact that they were referred to a weight reduction programme. Weight reduction programmes will inform Practices of the following for each patient referred and to which read code that data can be input under: Weight management plan started: TPP (Systm One) XaKiZ All other systems; 66CH. Weight management plan completed: TPP (Systm One) XaKia All other systems; 66CJ. Body Mass Index: TPP (Systm One) 22k.. All other systems; 22k.. Waist Circumference (where applicable): TPP (Systm One) Xa041 All other systems; 22N0. Percentage weight loss: TPP (Systm One) X76CD All other systems; not yet available Ideally these codes will be used every time patient is monitored in Practice, along with the read codes for being referred into a weight management programme which are detailed on page 13. Longer Term Weight Monitoring The referrer will be responsible for monitoring weight over the long term as part of the associated clinical outcome, which was designated as the reason for referral. This will enable evaluation of the impact of commissioned weight reduction programmes. All weights recorded by any service commissioned are required to be reported back to the patients General Practice. * Numerous studies have shown that a modest weight loss of 5% - 10% of bodyweight, significantly improves lipoproteins, hypertension, diabetes mellitus and insulin resistance, risk of osteoarthritis and its symptoms, risk of certain cancers and other risk factors for chronic conditions. Page 17 of 30

18 Pregnancy Please note that a pathway is being developed for obese pregnant women and pregnant women with diabetes. This is being developed alongside the maternity pathway that can be found in the Derby and Derbyshire Maternity Strategy. Preconception Individuals attending Primary Care who are obese (BMI =30) wishing to become pregnant should be informed that their chances of spontaneous conception are lower than those individuals of a lesser BMI. This is also the case with IVF treatment, with the chances of conception through IVF reducing as an individual s weight increases. Therefore these individuals should be advised of the services available through the obesity pathway, prior to becoming pregnant, as weight loss will improve their chances of conception, their own health and ultimately the health of their baby. Weight Reduction Options Women who are trying to become pregnant with a BMI = 28 with related co-morbidities or BMI =30 should be referred through the clinical care pathway appropriate to their BMI (See page 11). During Pregnancy Pregnant individuals who are obese (BMI =30) should be advised of the services available through the obesity pathway. Weight management, not weight loss, would be an appropriate clinical goal as determined by the referrer. It should be explained to obese women that obesity poses a risk to their health and the health of the unborn child. Advise of a healthy diet through practical and tailored information. Dispel any myths, such as eating for 2. Energy needs do not change in the first 6 months of pregnancy and increase only slightly during the final 3 months. Dieting during pregnancy is not recommended as it may harm the health of the unborn child. Practical advice regarding physical activity should be given. Moderate intensity physical activity will not harm the individual or her unborn child and recreational exercise is appropriate to stay fit. Iterate that it is important not to be sedentary and to build physical activity into daily life. After Childbirth A mother with a BMI = 28 with related co-morbidities or BMI =30 should be referred through the clinical care pathway appropriate to their BMI (See page 11). Women should be encouraged to breastfeed and be re-assured that moderate intensity physical activity and gradual weightloss will not adversely affect breast milk. For women with BMI =30, the risks posed to the health of an unborn child if they become pregnant again, should be explained. Page 18 of 30

19 Pharmacotherapy Drug treatments When to consider drug treatment Consider only after dietary, exercise and behavioural approaches have been started and evaluated. Consider for patients who have not reached their target weight loss or have reached a plateau on dietary, physical activity and behavioural changes alone. Before deciding to start treatment discuss the potential benefits and limitations with the patient, including the mode of action, adverse effects and monitoring requirements, and their potential impact on the patient s motivation. When prescribing, make arrangements for appropriate healthcare professionals to offer information, support and counselling on additional diet, physical activity and behavioural strategies. Measure weight, calculate BMI and document at the time of initial prescribing. Give information on patient support programmes. Follow the drugs summary of product characteristics. Continued prescribing and withdrawal Review regularly (weight and BMI) to monitor the effect of drug treatment, to reinforce lifestyle advice and the need for adherence. Drug treatment may be used to help people to maintain weight loss, as well as to continue to lose weight. Withdraw drug treatment if the person does not lose enough weight. Consider less strict goals for people with type 2 diabetes, because they may lose weight more slowly. Agree goals with the person and review regularly. If concerned about micronutrient intake, consider giving a supplement providing the reference nutrient intake for all vitamins and trace elements, particularly for vulnerable groups such as older people, who may be at risk of malnutrition. If withdrawing a person s drug treatment offer support to help maintain weight loss, as selfconfidence and belief in their ability to make changes may decrease. Always prescribe as acute prescriptions (not repeats) to ensure required weight loss/maintenance is achieved before prescribing. Page 19 of 30

20 Orlistat (Xenical) Prescribe only as part of an overall plan for managing obesity in adults who have: BMI of 28.0 kg/m2 or more with associated risk factors, or BMI of 30.0 kg/m2 or more. Do not continue treatment for longer than 3 months if the person has not lost at least 5% of their initial body weight since starting drug treatment (less strict goals may be appropriate for people with type 2 diabetes). Only continue for longer than 12 months (usually for weight maintenance) after discussing potential benefits and limitations with the patient. Co-prescribing with other drugs for weight reduction is not recommended. Stop treatment if:- Inadequate response (less than 5% weight loss at 12 weeks); Weight gain of 3kg after initial weight loss; Weight loss stabilises at <5% of initial body weight. Contraindications For contraindications and more detailed information on Orlistat please visit the website: - referring to the Summary of Product Characteristics (SPC). Waist Circumference When assessing a patients weight and associated risk factor status, waist circumference is at least as good an indicator of overall body fat as BMI. It is also the best anthropometric predictor of visceral obesity. Men with a waist circumference of 94 cm or greater (90 cm for Asian men) are at increased risk of obesity-related health problems. Women with a waist circumference of 80 cm or more are at an increased risk of obesity-related health problems. When BMI is greater than 35 kg/m 2, waist circumference does not add to the absolute measure of risk. Instructions for measurement of waist circumference may be found at: For patients who are muscular, waist circumference should be utilised alongside BMI to determine suitability for referral to weight reduction services. Page 20 of 30

21 DERBYSHIRE HEALTH REFERRAL and WAISTWISE REFERRAL FORM (please note: this form replaces all previous Health Referral and WaistWise referral forms) 1. PATIENT INFORMATION (16yrs +): 2. REFERRERS INFORMATION: NHS Number: Date of Birth: Referrers Name: Title: (Mr / Mrs / Ms / Miss) Gender: M / F Referrers Occupation: Name: Address: Telephone Number: Mobile Number: Address: Emergency Contact Name: Post Code: Referrers Address: Telephone: Date of Referral: GP Name (if different from referrer): Practice Name: 3. REFERRAL ELEGILIBITY CRITERIA Emergency Contact Telephone: Patient assessed as motivated? Yes No 4. REFERRAL CATEGORY & PATIENT OUTCOMES select one category only Primary Referral Category (select one only): 1 Only Expected Clinical Outcome: 1 Only Date: Baseline Measures (one set only) please record: Weight Management BMI 30+ or 28+ with Co-Morbidities Maternal Obesity 5% Weight Loss Height: Weight: BMI: Weight Management Appropriate measure: *outcome to be determined by Midwife Reduced or maintained Risk Score: CVD risk Improved Mental Health Mental Health Status: Test/Scale used: CVD Risk greater than 20% excluding age and gender Diagnosed Mental Health Issue Joint or Mobility Issue Improved Mobility Mobility Status: Test/Scale used: Respiratory Improved Lung Function Lung Function Measure: 5. MEDICAL HISTORY please tick and state as appropriate: Test/Scale used: Stable Angina / Ischaemic Heart Disease Mental Health Controlled Hypertension Stable Diabetes Managed Asthma Controlled COPD Stroke Additional relevant contraindications: 6. CURRENT MEDICATIONS or attach additional sheet 7. PHYSICAL HEALTH DATA if not recorded in Baseline Measures: Date: Weight: Blood Pressure Resting Heart Rate 8. PATIENT EXPECTED GOAL (why does this patient want to attend the programme/what do they want to achieve?): 9. DOES PATIENT NEED ADDITIONAL SUPPORT TO ACHIEVE GOAL? (e.g. Learning Disabled, Mobility issues, Carer) 10. OTHER NOTES 11. SIGNATURES: Clinician: (I confirm this patient meets the criteria and has been appropriately assessed as suitable for the programme) Patient: The Derbyshire Health Referral Scheme has been explained to me. I want to participate and I give permission for this and any additional information concerning my participation to be passed onto the Health Referral Scheme. I agree for Health Referral to contact me in the future for follow-up. I understand that my information will be electronically stored within the NHS for the purpose of evaluation and monitoring and will not be shared or used outside of those realms. Page 21 of 30

22 Please return to: Health Referral Central Administration Team, Derbyshire Community Health Services, Babington Hospital, Derby Road, Belper, Derbyshire. DE56 1WH. Or Any queries please contact: Copies of this form can be downloaded from 20Reduction%20Services%20Referral%20Form.pdf Thank you FOR DERBYSHIRE COMMUNITY HEALTH SERVICES AND HEALTH REFERRAL STAFF USE ONLY: Appointment Date: Appointment Time: Venue: Instructor: Date Received: Initial Consultation Week 12 Physical Activity Level (required) Weight (required for weight reduction) Waist (required for weight reduction) Systolic BP (optional) Diastolic BP (optional) Resting Heart Rate (optional) Peak Flow (optional) Ethnicity Origin Please tick the appropriate box: White British Other White Background Black African White and Black Caribbean White and Asian Chinese Asian Indian Asian Bangladeshi Other Not Stated Occupation Code Please tick the appropriate box: Unemployed Self-Employed Manual Not Stated Physical Activity Level (required) Weight (required for weight reduction) Waist (required for weight reduction) Systolic BP (optional) Diastolic BP (optional) Resting Heart Rate (optional) Peak Flow (optional) White Irish Black Caribbean Other Black Background White and Black African Other Mixed Groups Other Ethnic Groups Asian Pakistani Other Asian Background Retired Clerical Professional Page 22 of 30

23 Appendix 2 Patient Information Leaflet Are You Ready Yet? It has been suggested to you that it would be beneficial to your health for you to lose weight. However to lose weight requires that you are motivated to make changes to your lifestyle. At the moment you have indicated that you are not ready to do this. This leaflet is designed to give you some information on weight and the risks it poses to your health. More than half the adults in the UK are heavier than is recommended, and over 20% of the adult population is classed as obese, so you are not alone. Health Risks Being overweight or obese is associated with an increased risk of many health conditions including: Type 2 Diabetes High Blood Pressure Stroke Sleep Apnoea Joint and Mobility problems Benefits of Weight Loss A realistic aim for weight loss is to lose 5-10% of your weight. For example, if you weighed 100kg (15 stone 7Ibs), a weight loss of 5-10kg (10-22Ibs) can be extremely beneficial to health, meaning you are much less likely to develop the conditions listed above. If you already suffer from high blood pressure, osteoarthritis, or diabetes these conditions are likely to improve. Many people who lose weight say they feel better, have more energy and find that their self-esteem has improved. Your Choice Motivation is vital for anyone wishing to succeed at weight loss. If you feel at any point in the future that you would be willing to participate in a weight reduction service, please make an appointment with a Practice Nurse or Health Care Assistant at your General Practice and they will explain all the options available to you. All services offered are delivered according to guidelines developed by the Primary Care Trust and deliver common sense, practical advice and tailored support to help you achieve a weight loss that is realistic. Page 23 of 30

24 Appendix 3 Patient Information Leaflet Maintaining the Weight Loss A lot of people lose weight, but at the end of the diet they put the weight straight back on. As you will have learnt through the weight management service you participated in, it is vital that you have a permanent change in your attitudes and lifestyle. This usually means: Maintaining a healthy eating plan Being physically active wherever possible Possibly a change in the whole family s eating habits. It is difficult for one family member to shop and eat differently from the rest of the family. This will produce health gains for the whole family as an added bonus. Maintaining a healthy lifestyle should not be a chore; it may take time to learn to enjoy different foods, meals and recipes. There is no harm in having the occasional treat, as long as it is occasional and activity levels are maintained. Most people find it easier to keep up good habits when they have support. That support could come from, your family, your friends; if you attended a group weight reduction programme it may come from fellow participants; you may have found support through attending the Health Referral Scheme regularly, or you may prefer to go it alone as one size does not fit all and it is important that you maintain your healthier lifestyle in a way that is enjoyable and sustainable for you. Congratulations on achieving your weight loss. Move forward with a healthier lifestyle and a happier you and good luck maintaining those changes. Page 24 of 30