All patients will be expected to engage with a weight loss programme before consideration of weight loss medications. In order to manage patient expectations, referrals specifically requesting injectable weight loss medications will be returned.

Patients are not eligible for re-referral to Tier 3 services for 2 years from the date of discharge from the service.

Self-referrals to Tier 3 Weight Management Services are not accepted.

To access Tier 4 (bariatric surgery) services, patients must be referred to Tier 3 Specialist Weight Management Services. The Tier 3 team will then refer to Tier 4 if appropriate.

Patients who undergo self-funded bariatric surgery, including overseas, who have not completed a Tier 3 Weight Management Programme and been deemed eligible for bariatric surgery by a Tier 3 specialist weight management team, are not eligible for referral or follow up by NHS Weight Management Services.

Services are provided across Devon as follows:

• Plymouth and West Devon - Live Well South West
• South Devon - Torbay and South Devon Foundation Trust
• North and East Devon - Royal Devon University Hospital

Tier 3 Specialist Weight Management Services provide one to one assessments, information, and treatment in accordance with NICE guidelines, encouraging long term behaviour change through promoting healthy eating, physical activity and addressing the psychological barriers to enable healthy relationships with food. Patient information on the services can be found here.

Patients are offered up to 12 months of MDT weight management support.

Please note, patients are not eligible for re-referral to Tier 3 services for 2 years from the date of discharge from the service.

For prescribing of injectable weight loss medications (e.g. Saxenda (Liraglutide) and Wegovy (Semaglutide) please note:

• Patients are required to meet the referral requirements for the Tier 3 Specialist Adult Weight Management Services.
• All patients will be expected to engage with a weight loss programme before consideration of weight loss medications.
• In order to manage patient expectations, referrals specifically requesting injectable weight loss medications will be returned.
• Specialist health professionals and commissioners are presently working together to identify the processes needed to enable these medications to be prescribed.

For additional information on weight management services (including medications), patients can be directed here.

Tier 3 Inclusion criteria

Tier 3 Routine referral criteria

Patients aged 18 years or more:

• With a BMI of at least 40kg/m2 ¥
• With BMI of at least 30kg/m2 ¥ and newly diagnosed Type 2 Diabetes Mellitus (less than 6 years). If your practice has signed up to LES, please consider referral to the NHS Type 2 Diabetes Remission Pathway.
• Who have previously had NHS Bariatric Surgery [patients will be assessed by a Tier 3 weight management specialist]
• With BMI of at least 35kg/m2 ¥ and one or more of the following comorbidities:
  • Established T2DM (equal to or more than 6 years)
  • History of gestational diabetes
  • Non-diabetic hyperglycaemia (HbA1c 42-47 mmol/mol within 6 months of referral date) and a high risk of cardiovascular disease based on risk factors such as hypertension and dyslipidaemia (defined as the presence of 1 or more of: a total cholesterol level of more than 5 mmol/litre, systolic blood pressure of more than 140 mmHg, or a high-density lipoprotein level of less than 1.0 mmol/litre for men and less than 1.3 mmol/litre for women)
  • Metabolic dysfunction-associated fatty liver disease (MAFLD)
  • Infertility in which weight is a barrier to assisted conception therapy.
  • Obstructive Sleep Apnoea, diagnosed by a respiratory specialist.
  • Gastro-oesophageal reflux disease where management of choice may be bariatric surgery, as determined by an upper GI specialist.
  • Non sight threating Idiopathic Intracranial Hypertension (IIH)
  • Patients with stable mental health who are taking atypical antipsychotic with high risk of weight gain (clozapine or olanzapine).
  • Uncontrolled Hypertension (on 3 or more antihypertensive medications)
  • Hyperlipidaemia or hypertriglyceridemia requiring pharmacological management or specialist review as per NHS Summary of National Guidance for Lipid Management for Primary and Secondary Prevention of CVD: lipid-management-pathway-v6.pdf (england.nhs.uk)
  • Cardiovascular disease where outcomes are likely to improve with weight loss, as determined by a cardiologist.
  • Respiratory disease thought to be exacerbated by weight, as determined by a respiratory physician.
  • Renal disease where weight loss is likely to improve outcome or slow progression to dialysis as determined by a renal specialist.
  • Hidradenitis suppurativa, as determined by a dermatologist.
  • Evidence indicates that weight loss will significantly improve surgical outcome and has been recommended by the surgeon (excluding urgent criteria below). Please provide full details, including clinical justification, timescales, and target weights. Referral will be prioritised appropriately. Exceptional cases will be discussed with clinical teams across Devon.

In line with the Primary and Secondary Care Interface agreement, it is expected that secondary care clinicians will make these referrals to the Weight Management Service.

If the specialist team in Secondary Care are uncertain regarding the referral appropriateness and have asked for a primary care opinion, please attach a confirmatory letter (e.g., clinic letter) confirming the indication/advice from secondary care to aid triage.

¥ For people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family backgrounds please reduce BMI thresholds by 2.5 kg/m2

Tier 3 Urgent referral criteria

Patients aged 18 years or more:

• Awaiting organ transplantation; advised by transplant team.
• Awaiting urgent cardiac surgery; advised by cardiac team. These referrals will be assessed on an individual basis.
• With Idiopathic Intracranial Hypertension (IIH) with sight threatening disease; advised by ophthalmology.

In line with the Primary and Secondary Care Interface agreement, it is expected that secondary care clinicians will make these referrals to the Weight Management Service.

If the specialist team in Secondary Care are uncertain regarding the referral appropriateness and have asked for a primary care opinion, please attach a confirmatory letter (e.g., clinic letter) confirming the indication/advice from secondary care to aid triage.

Exclusion criteria

Patients who are:

• Not registered with a Devon General Practice.
• Age below 18 years
• Patients who cannot attend assessment appointments face to face ⃰
  • please contact your local weight management team to discuss suitability of the service if required). †

• Patients in care settings in which food is provided
  • please contact your local weight management team to discuss suitability of the service if required). †

• Pregnant Women
• Patients who are unwilling or unable to engage with the complexities of the service e.g., patients with significant learning differences that would prevent meaningful engagement with the behavioural weight management / group based treatments
  • please contact your local weight management team to discuss suitability of the service if required). †

• Patients who undergo self-funded bariatric surgery, including overseas, who have not completed a Tier 3 Weight Management Programme and been deemed eligible for bariatric surgery by a Tier 3 specialist weight management team.

Face to Face Initial Assessment

⃰ Face to Face initial assessment is required for the following reasons:

1. Physical data collection, e.g. weight, BMI, exercise capacity.

Bariatric equipment held in the community may not have a high enough weight limit. A verified weight is essential for onward planning.

2. Medical examination e.g. fat distribution, medical cause of obesity, optimising medical co-morbidities.

3. To establish rapport.

4. As a measure of engagement and readiness for change. After their initial assessment, many patients will then go into remote groups.

Please contact your local weight management team to discuss suitability of the service if required. †

† Tier 3 Weight Management Service Contact Details

Please put ‘Suitability of patient for service’ in the subject

• Plymouth & West Devon - livewell.weightmanagement@nhs.net or 01752 434623
• South Devon - Weightmanagement@nhs.net or 01803 654823
• Exeter & East Devon - 01392 402294
• North Devon - 01271 322306

History and Examination

• Clarify with the patient that they are ready to make behaviour change.
• BMI

(please reduce BMI thresholds by 2.5 kg/m2 for people from South Asian, Chinese, and Black African or Caribbean family backgrounds. This is NICE guidance and relates to a greater propensity in these ethnic groups to develop diabetes and its complications)

• Blood pressure (BP) – please use appropriately sized cuff.

• Check for signs of weight-related comorbidities and consider primary causes of Obesity (see ‘Investigations’).

The following pre-referral screening bloods must be performed and actioned within the preceding 6 months of any referral to Tier 3 Weight Management Service, or the referral will be returned:

• Full blood count to exclude anaemia secondary to micronutrient deficiencies.
• Urea and Electrolytes to screen for obesity-related nephropathy.
• Lipid profile to screen for hyperlipidaemia (non-fasting profile is satisfactory).
• HbA1c to screen for Type 2 Diabetes Mellitus.
• Thyroid function tests to screen for hypothyroidism, a primary cause of Obesity.
• Liver function tests to screen for Metabolic dysfunction-associated fatty liver disease (MAFLD).

Local specialists also recommend checking the following blood tests for individuals with a BMI greater than 35 (due to the high prevalence of micronutrient deficiencies in this group):

• Vitamin B12
• Ferritin
• Folate
• Bone profile
• Vitamin D

Identify and manage weight-related comorbidities.

Specialist Weight Management services screen for Binge Eating Disorder (BED) and Obstructive Sleep Apnoea (OSA) and refer patients to the relevant service if required. However, they do not have capacity to manage all weight-related comorbidities. Please screen for comorbidities in primary care and manage as appropriate.

Review of medications known to cause weight gain

Some common medications known to cause substantial weight gain:

• Steroid hormones e.g. prednisolone
• Antidiabetic drugs e.g. pioglitazone
• Antidepressants e.g. amitriptyline, mirtazapin
• Aentiepileptic drugs e.g. levetiracetam, valproic acid, carbamazepine
• Antipsychotics e.g. olanzapine, quetiapine, clozapine

Consider prescribing alternatives where clinically appropriate, and seek specialist advice if required.

Optimise medical management of Type 2 Diabetes Mellitus, prioritising medications that help to promote weight loss.

Consider referral to the NHS Type 2 Diabetes Remission (T2DR) pathway for patients with newly diagnosed Type 2 Diabetes.

Tier 4 weight management services offer support for people with severe, complex obesity inclusive of bariatric surgery, obesity medicine MDTs, post surgical and annual follow up.

Patients are eligible for consideration of bariatric surgery only after following 12 months of specialist weight management support via Tier 3 services. Patients must meet all the criteria for onward referral as outlines by the Tier 3 team. This includes engagement with the programme, achieving a target weight, be a non smoker and be medically and psychologically fit for surgery.

Inclusion criteria

Patients over the age of 18 who:

• Have engaged with a tier 3 specialist weight management service AND
• Have a BMI of 40 or above (at entry to tier 3) OR
• Have a BMI between 35 kg/m2 and 39.9 kg/m2 (at entry to tier 3) with co-morbidities OR
• Have a BMI of 30 or above (at entry to tier 3) and newly diagnosed Type 2 Diabetes Mellitus (less than 6 years) OR
• Have a significant health condition that could be improved if they lost weight

Exclusion criteria

• Have not engaged with a tier 3 specialist weight management service.
• Have not met weight loss target set by Tier 3 team
• Have not been deemed fit (medically or psychologically) for onward referral by the Tier 3 team

To access Tier 4 (bariatric surgery) services, patients must be referred to Tier 3 Specialist Weight Management Services. The Tier 3 team will then refer to Tier 4 if appropriate.

Patients are supported to understand; the risks and consequences of bariatric surgery, the need for behaviour changes pre- and post-operatively and assistance in the decision-making process.

Additional information

Post-bariatric surgery monitoring

The British Obesity and Metabolic Surgery Society (BOMSS) have created a GP Hub to provide information to healthcare professionals: Introduction to the BOMSS GP Hub

BOMSS have created an accessible summary of nutritional guidance to support GPs managing adults who have had bariatric surgery: BOMSS post-bariatric surgery nutritional guidance for GPs

Further information is available on the Bariatric Service (Tier 4) on the following websites:

Bariatric Surgery (University Hospitals Plymouth NHS Trust)

Bariatric Surgery (Somerset NHS Foundation Trust)

Patients who undergo self-funded bariatric surgery, including overseas, who have not completed a Tier 3 Weight Management Programme and been deemed eligible for bariatric surgery by a Tier 3 team, are not eligible for referral or follow up by NHS Weight Management Services.

Referral Instructions

All patients will be expected to engage with a weight loss programme before consideration of weight loss medications. In order to manage patient expectations, referrals specifically requesting injectable weight loss medications will be returned.

Patients are not eligible for re-referral to Tier 3 services for 2 years from the date of discharge from the service.

Self-referrals to Tier 3 Weight Management Services are not accepted.

The only route for NHS funded Tier 4 (bariatric surgery) for patients in Devon is via referral from the Tier 3 specialist weight management services. There is no direct Tier 4 referral pathway from primary care.

Patients who undergo self-funded bariatric surgery, including overseas, who have not completed a Tier 3 Weight Management Programme and been deemed eligible for bariatric surgery by a Tier 3 team, are not eligible for referral or follow up by NHS Weight Management Services.

Please include the following in your referral letter or referral form:

1) Examination Findings (BMI, BP)
2) Mandatory blood tests results attached (abnormal results appropriately managed)
(see Investigations)
3) Referral criterion clearly stated

The referral forms are designed to reduce referral time and to minimise returned referrals.

Use of the referral form is advised. However, referrals will be accepted as long as all the essential information is included.

Referral form - Plymouth and West Devon - no merge fields

Patient information

My Health Devon - Managing Your Health & Wellbeing (myhealth-devon.nhs.uk)

BestYou App (provided by ICE Creates)

Best-You

Patients should be signposted to the ICE Creates’ app, ‘BestYou’. The BestYou app will support wider health and wellbeing goals including increasing activity levels, stopping smoking, managing weight and reducing alcohol consumption. The app is free to download and use for Devon residents.

In addition, patients could be made aware of the following (national) NHS online resources:

NHS Better Health Programme

NHS Better Health Programme - lose weight

Information and links to healthier eating habits, getting more active and losing weight. Includes access to the NHS Weight Loss Plan, a 12-week plan supporting individuals to set weight loss goals, plan meals, make healthier food choices, be more active and record activity/progress (available on the App Store or Google Play).

NHS Digital Weight Management Programme

NHS Digital Weight Management Programme

12-week online lifestyle programme accessed via smartphone or computer. Eligibility - BMI of 30 or more (27.5 or more for people from black, Asian and ethnic minority groups) with diabetes (Type 1 or 2) or hypertension, or both. Support is through digital content or personal coaching.

Healthier You NHS Diabetes Prevention Programme

Healthier You NHS Diabetes Prevention Programme - Devon

Held face-to-face at locations in Devon or digital online group sessions. Designed to help prevent diabetes through healthier eating, physical activity, problem-solving, stress reduction and coping skills. Please see information on eligibility criteria.

NHS Type 2 Diabetes Remission Pathway

NHS type two diabetes path to remission programme

Healthy Steps for Families (Better Health)

Better Health - Healthier Families

Helping families set goals and track progress to enjoying cooking together, cutting down on sugar and eating 5 a day.

Healthy Recipes for Families (Better Health)

Better Health - Healthy recipes

Affordable family meals with easy step-by-step recipes.

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: December 2024