REferral form for the BNSSG

TIER 3 MULTI-DISCIPLinary Weight

Management SERVICE (BRISTOL patients)

Multi-Disciplinary Weight Management Service

This service provides a non-surgical service for Bristolpatients 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 informationyouthinkisrelevanttothispatient’scase(medication list, clinicletters 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, all of the blood tests have been completed and a copy of the evidence from the tier 2 service that the patient has complied with the service for the required time period is provided.

Criteria for Referral to the BNSSG Tier 3 Multi-Disciplinary Weight Management Service

In order to refer a patient to this service they must be in one of the following three categories* ()

BMI 40+¹without co-morbidities and patient has evidence of 2 years of attempted weight loss, including engagement and compliance with tier 2 interventions
BMI 35+¹ with co-morbidities and patient has evidence of 2 years of attempted weight loss including engagement and compliance with tier 2 interventions
BMI 50+¹

(¹a tolerance of BMI 2.5 on each criteria above for at risk groups: black African, Caribbean and South Asian origin.

² Obesity related co-morbidities accepted: Established cardiovascular disease; Type 2 diabetes; Impaired glucose tolerance; Severe hypertension; Obstructive sleep apnoea (OSA); Polycystic ovarian syndrome; Osteoarthritis and on medication; Severe lower limb major joint disease (requiring orthopaedic intervention); idiopathic intracranial hypertension.

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 has not undergone previous weight loss surgery
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?

If the patient is not appropriate for referral to this service, the possible other options for care and support can be seen on the pathway attached to this form.

Thank you for referring your patient to North Bristol NHS Trust

Part1–PatientInformation

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

Significant co-morbidities

Yes / No / Year diagnosed / Yes / No / Year Diagnosed
Type 2 Diabetes / Metabolic syndrome
Hypertension / PCOS
Sleep Apnoea / Dyslipidaemia
Heart Disease / Osteoarthritis
Idiopathic intracranial hypertension / Severe joint disease

Other significant medical history

Diagnosis / Duration / Details of current therapy optimal? / Yes / No
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:
Has the patient demonstrated a commitment to making lifestyle changes? / Yes / No

Part 2b: Investigations/Blood Test Results

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

Full blood countB12 and folate

Urea and electrolytesThyroid function tests (TSH and free T4)

Liver function testsFasting glucose and lipid profile

Calcium and Vitamin DHbA1c

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 with Anorexia Nervosa, Bulimia Nervosa or Binge Eating Disorder?
Do they have a history of Anxiety?
Do they have a history of Depression?
Any history of/ current use of
recreational drug use / dependency?
Any history of/ current use of heavy alcohol use / dependency?
Have they ever self-harmed or attempted suicide?

Details of Mental Health Disorders

No
()
History of auditory/ visual hallucinations
Psychosis
History of any other mental health problems
Are they under the care of the Community Mental Health Team?
Are they taking any medication for their mental health that could increase weight?
Has the person ever been referred for therapy/ to mental health team?

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 ManagementCo-ordinator

Southmead Hospital

Brunel Building

Level 6, Gate 10

Westbury on Trym

Bristol

BS10 5NB

Tel: 01174146421

Fax: 0117 4149448

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