REferral form for the BNSSG TIER 3 MULTI-DISCIPLinary Weight Management SERVICE (BNSSG patients)

Multi-Disciplinary Weight Management Service

This service provides a non-surgical service for BNSSG patients with severe or complex obesity. It will offer a specialist multi-disciplinary weight management assessment (including psychological, dietician and medical support), followed by a 6-12 month programme of care comprising of MTD assessments, 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.

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 (medication list, clinic letters etc). Please could you ensure that the relevant blood tests in section 2b have been completed and the results (within the last 3 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* (ü)

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 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.

Status & entry criteria* (ü)

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 a 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 early within the last 12 months
Patient is not pregnant
Patient in agreement with referral to weight management team and understand they must demonstrate a long-term commitment to making lifestyle changes (dietary and activity)
NICE guidance starts that “all appropriate measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least six months. Do you consider this to be the case?

Thank you for referring your patient to North Bristol NHS Trust

Part 1 – Patient Information

Name
Address
Date of Birth
Telephone
Mobile
Email
NHS Number
GP Name
GP Address
Weight (kg) / Height (m)
BMI (kg/m2) / BP (mmHg)

Part 2a: Medical Assessment

Co-morbidities

Yes / No / Year diagnosed
Type 2 Diabetes
Hypertension
Sleep Apnoea
Heart Disease
Idiopathic intracranial hypertension
Does the patient smoke? (number)
Patients must be informed that surgery will not be offered until they have stopped smoking / /day
How much alcohol does the patient drink? / units
per wk:

Other significant medical history

Diagnosis / Duration / Details of current therapy optimal? / Yes / No

Medications – please write below or attach list

Medication / Dose / Medication / Dose / Medication / Dose

Part 2b: Investigations/Blood Test Results

The following blood test results should be attached to the referral:

Full blood count B12 and folate

Urea and electrolytes Thyroid function tests (TSH)

Liver function tests Fasting glucose and lipid profile

Calcium and Vitamin D HbA1c

Confirm Done
Anaemia excluded (if iron deficiency anaemia, needs further investigation before referral to weight management team)
Thyroid function checked (treat as required)
Liver function normal (if abnormal liver function tests, request ultrasound assessment prior to referral)
Assess nutritional status and treat appropriately: B12, folate, vitamin D, calcium

Part 3 – Psychological Assessment

/ Yes (please include brief details of treatment received) / No /
Has the patient ever been formally diagnosed or treated with Anorexia Nervosa, Bulimia Nervosa or Binge Eating Disorder?
Do they have any past or present mental health problems such as Anxiety or Depression etc? Please provide information on treatments undertaken.
Have they been treated for any other mental health problems under the care of the community mental health team? If so please provide details and current mental health stability
Do they report any past or current substance misuse, such as recreational or prescription drugs or alcohol? Please provide information on any treatments undertaken.
Have they ever self-harmed or attempted suicide or had recurrent suicidal ideation?
Does the person emotionally regulate with food to make themselves feel better?
Please consider if the patient needs a referral to Bristol Wellbeing Services, South Gloucestershire Talking Therapies or Positive Steps for therapy to help manage depression, anxiety etc at the time of making this referral.

Part 4 – Dietary Assessment

Intervention Tried / Successful Weight Loss? Please circle / Other information
Programmes Tried (please circle):
·  Commercial slimming clubs
·  Diets
·  Practice based interventions
·  Group sessions
·  Individual Dietetic sessions
·  Activity schemes / Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Which weight loss medications has the patient tried?
·  Orlistat
·  Sibutramine
·  Alli
·  Other...... / Yes / No
Yes / No
Yes / No
Yes / No
Name of Referring Doctor / Signature / Date

Please send this referral to:

Weight Management Co-ordinators

Southmead Hospital

Brunel Building

Level 6, Gate 10

Westbury on Trym

Bristol

BS10 5NB

Tel: 0117 4146421

Fax: 0117 4149448

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