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Tier 3 weight management intervention
There has been extensive debate as to the role and overall benefits of Tier 3 non-surgical specialist weight management services. The new clinical commissioning policy for Complex And Specialised Obesity Surgery issued in April 2013 by the NHS Commissioning Board brings this debate into even sharper focus. Guidelines state that all bariatric surgery candidates must in the first instance access local Tier 3 multi-disciplinary specialist weight management services for a period of 12 to 24 months. For patients with a BMI over 50 the minimum acceptable period is six months. This raises a question around the role and responsibilities of these services. Can they offer an alternative non-surgical pathway or is their primary function to provide multi-disciplinary preparation for surgery?
As the field of obesity treatment matures, research suggests1,2 that not only is it difficult for patients to achieve a weight loss significant enough to improve their health status, but also available treatments are not supporting long-term successful weight maintenance. Bariatric surgery is largely considered to be the only effective treatment for obesity it is advocated by the National Institute of Clinical Excellence (NICE). According to Shedding The Pounds, (September 2010) compiled by the Office of Health Economics, ‘between 11,000 and 140,000 people in England currently qualify for bariatric surgery under NICE guidelines, while the actual number of surgeries that took place in England in 2009-10 was 3,607.’
It is clear that demand for bariatric surgery in the United Kingdom exceeds provision and there is a need for a more sophisticated model to manage the demand for obesity services.
Bariatric surgery is often portrayed by the popular media as a ‘magic cure’ that places little responsibility for a good outcome on the recipient. However success in bariatric surgery demands a capacity to make significant lifestyle changes and modify eating behaviour. It provides a window of opportunity of 18 to 24 months for patients to implement the changes neccessary. As with other treatments surgery is unlikely to deliver long-term weight maintenance if patients do not make fundamental changes. Whether a patient is treated in a specialist weight management service or proceeds onto a surgical pathway a growing body of evidence suggests3 that programmes combiing psychological behaviour change, dietetics and a physical activity component are the most effective model for long term weight maintenance.
The Service Model
The Bariatric Consultancy has been developing and delivering specialist multi-disciplinary Tier 3 weight management programmes since 2008. We currently deliver two services across the South of England, offering treatment to around 600-700 patients a year.
The service model is psychologically led. In March 2011 the National Obesity Observatory (NOO), published its paper Obesity and Mental Health, concluding that there are strong bi-directional associations between obesity and mental health. Research also suggests obesity is associated with high levels of childhood maltreatment,4,5 which manifest in adulthood as complex mental health problems resulting out of a history of trauma and poor attachment.6,7 These early experiences often result in disordered eating and a reliance on food for emotional regulation. It is our experience that by addressing the roots of a patients eating behaviour they are more able to understand their triggers and develop an alternative means of emotional regulation. Patients who have an intensive psychological intervention have shown high retention rates in the service and engage more extensively with the dietetic and exercise components. Our research has shown that patients who adhere to the programme will lose between 5-10% of their excess weight.
Since implementing these services we have experienced a significant impact on the numbers of patients requesting surgery. In one locality over a 12 month period the number of patients opting for surgical weight loss was reduced by 70%. Tier 4 providers within the pathway have reported that patients are better informed and that only those who are medically and psychologically prepared are accessing surgical services.
Our specialist weight management service fulfils the criteria set out by NICE (2006), and also the new commissioning policy (April 2013). Treatment is multi-disciplinary delivered by specialist clinicians, including physicians, dietitians, psychological therapists, and exercise facilitators. The service model provides a multi-disciplinary intervention including medical management, dietetics, psychological therapy, and an exercise component. A programme of this kind identifies those who cannot commit to lifestyle changes and are unlikely to achieve a good outcome from surgery. It also identifies those whose psychological status is not sufficently robust for them to undergo surgery, along with those whose medical conditions, eating behaviour or psychological disorders suggest the need for prior treatment.
Our specialist services are offered to patients with a BMI of 35≥ and are delivered locally to the patient usually in General Practices or Health Centres.
Patients are also able to access our service post surgery for psychological management if they are unable to make sufficient change to support a good outcome.
We have developed a four-phase treatment intervention that offers:
- Multi-disciplinary Assessment
- Intensive Treatment Phase (12 weeks)
- Maintenance Phase (nine months)
- Tier 4 Assessment and Preparation
Our model is psychologically led with all patients accessing an intensive psychological therapies intervention.
Clinics are spread geographically across localities and work to address any health inequalities present.
This takes place in two stages. Initially new referrals undergo a motivational interview carried out by a patient coordinator usually by telephone. This will assess a patients readiness to change. Patients accepted onto the programme are then assessed by the multi-disciplinary team. Collection of baseline data such as weight, BMI, and physiological markers, resting heart rate, blood pressure, and mobility assessment form part of this process. The results of the assessments determine an individual’s treatment plan. Patients are also screened for medical problems and unresolved complex mental health issues. This may result in a specialist referral to acute services or Community Mental Health Teams.
Treatment is primarily delivered in a group consisting of 10-15 participants. The programme is carried out over 12 consecutive weeks and is based around Cognitive Behavioural Therapy to facillitate behaviour change. There is also an educational dietetic component, and participants are prescribed activity goals and encourgaed to engage in community based activities and home exercise. All patients receive follow up one to one sessions with the psychological therapies team and dietitians at six, nine and twelve months. Patient’s emotional well-being is monitored at the start and completion of the Intensive phase using two outcome questionnaires, Clinical Outcomes in Routine Evaluation (CORE), and The Rosenberg Self Esteem Scale.8,9
Patients that are considered not to be psychologically robust enough for the group programme, are offered a similar treatment intervention but based on one to one contacts with a psychological therapist and dietitian but still encouraged to join the group exercise programme.
Maintenance treatment takes place over a nine month period. It is patient led and incorporates regular contact with the clinical team. Patients are also invited to attend support group meetings that are led by one of the therapy team. Physiological and psychological markers along with weight and BMI are collected at six, nine and twelve months.
Tier 4 Assessments and Preparation
Patients are not considered for onward referral to a surgical service until they have completed at least six months treatment. Bariatric surgery will only be considered for patients once the MDT have agreed that all other avenues of non surgical weight loss have been exhausted and that the patient is both medically and psychologically prepared. Patients must also have demonstrated a commitment to the Tier 3 programme and have shown the ability to address behaviour change even if their weight loss has been poor.
Patients proceeding to surgery will go through a preperation process. This includes a specialist medical assessment with a Bariatric Physician and attendance at a surgical seminar which sets out to educate patients on every aspect of surgery. This will include the Tier 4 journey, and post surgical dietary behaviour and lifestyle changes. Patients are also educated on the problems associated with skin folds, and potential medical and psychological complictions. Patients are then provided with a list of approved surgical centers that are available to their area, and asked to research their preferred provider before making a final choice.
Once a patient has been accepted on to a surgical pathway, they are discharged from our service. Developing close communication with surgical providers ensures that a patients progess is monitored and each patient is contacted by telephone six weeks post surgery by the patient coordinator. If a patient is found to be struggling with psychological change they can be re admitted to the Tier 3 service for a further intervention.
The success of our services has been an understanding of the complex needs of this patient cohort and the requirement to tailor services directly for them. We have also been responsible for educating and training other clinicians within the obesity pathway on the management of this complex patient group.
The debate around the part specialist Tier 3 weight management services have to play within a bariatric surgery pathway will continue. As yet there is no established standardised commissioning model. The services already commissioned are in their infancy and there is no long term data available to establish their efficacy in weight reduction and maintenance. However the responsibility they take for the in depth education and preparation of surgical candidates is measurable and should be evident in patients who are referred on to bariatric surgery pathways and are screened by the surgical multi-disciplinary teams.
- 1.Klem, M.L.,Wing, R.R., Lang, W., McGuire, M.T., Hill, J.O. (2002) Does Weight Loss Maintenance Become Easier Over Time? Obesity Research, 8 (6): 438-444.
- Anderson, J.W., Grant, L., Gotthelf, L., Stifler, L. (2007). Weight loss and long-term follow-up of severely obese individuals treated with an intense behavioral programme. International Journal of Obesity 31(3): 488–493.
- Cooper, Z., and Fairburn, C.G. (2001). A new cognitive behavioural approach to the treatment of obesity. Behaviour Research and Therapy, 39, 499-511.