Tier 3 Weight Management (Interim)

Threshold

General Principles

This threshold policy for Tier 3 Specialist weight management support applies to patients registered with a Norfolk and Waveney GP.

Significant transformation to obesity care is expected in the medium term. Therefore, this clinical threshold policy has been developed as an interim measure and will be reviewed in the light of important new guidance or changes to care pathways.

On a case-to-case basis, patients might be eligible for this intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request.

This policy is intended for suitably qualified referring clinicians working in primary care. Clinicians should assess their patients against the criteria within this policy prior to a referral and/or treatment.

Clinical Threshold

Tier 3 specialist weight management services can support access to intensive behavioural interventions, bariatric surgery, specialist psychological and dietetic support and the higher strength GLP-1 RAs treatment options, including Saxenda® (liraglutide) and Wegovy® (semaglutide).

For all people requesting referral, clinicians should use shared decision making to determine with the individual that they feel ready to engage with the programme and would like to be referred at this time. Ability to adhere to weight loss programmes correlates with weight loss achieved.

Currently, it is not possible to provide access to SWMS for all eligible people in line with NG246. Consequently, people with higher clinical need will be prioritised as detailed in the phasing cohorts below. Patients able to access the service currently, must meet the eligibility criteria as per the Norfolk and Waveney Clinical Threshold Policy, and the prioritisation phase 1 (1 & 2) depending on what funding allows for.

Inclusions:

Patients aged 18 years and over with BOTH of the following criteria

BMI of ≥35 kg/m² (usually reduced by 2.5 kg/m² for people from Black, Asian and ethnic minority backgrounds)

BMI between 30-34.9 kg/m² (usually reduced by 2.5 kg/m² for people from Black, Asian and ethnic minority backgrounds) who meet the criteria for referral to specialist weight management services in NICE’s guideline on obesity ^1∗

AND

Prioritised in the following phased cohorts, as underpinned by ‘A joint position statement by the Society for Endocrinology and Obesity Management Collaborative UK’ ^2*; developed as a result of the need for guidance during phasing in of semaglutide (Wegovy®) and future medical therapies to help clinicians prioritise based on clinical need. Currently, access will be provided for Phase 1 priority cohort only. Additional cohorts will be considered as the financial position evolves.

Phase 1: ≥ONE of the following conditions, which could be improved by weight loss:

Precancerous or cancerous conditions in which weight loss would improve outcomes or aid access to therapies
Patients requiring urgent weight loss for organ transplant
Idiopathic intracranial hypertension (IIH) requiring frequent lumbar punctures and/or with visual compromise
Patients requiring planned time-sensitive surgery (including bariatric surgery) for reversible, life-limiting conditions and who have severely restricted activities of daily living (ADLs), where high BMI is the primary barrier to surgery and weight loss is essential to access treatment
Weight loss required for assisted conception in women under the care of a fertility service, in cases where weight loss would be beneficial ^3*
Severe obstructive sleep apnoea (OSA), obesity hypoventilation syndrome (OHS) – where the severity has been indicated by an Apnea Hypopnea Index (AHI) of >30A and/or severe asthma
Proven genetic cause of obesity and not eligible for Setmelanotide.
An individual who meets the clinical qualification for Phase 2 but also has a condition such as learning disability (LD) or severe mental illness (SMI), should be prioritised as Phase 1 eligibility ^4*
Young adults requiring ongoing support, transitioning from paediatric tier 3 obesity services ^5*
Where an individual meets the eligibility criteria for access to tirzepatide in primary care but where the primary care clinician requests additional support from specialist services.

Phase 2: ≥THREE of the following conditions, which could be improved by weight loss:

- Chronic kidney disease (stages 3 or 4)
- Hypertension (established diagnosis and requiring blood pressure lowering therapy)
- Idiopathic Intracranial Hypertension (IIH)
- Metabolic dysfunction-associated steatohepatitis (MASH) ^6*

Moderate obstructive sleep apnoea (OSA)
Polycystic Ovary Syndrome (PCOS)
Type 2 Diabetes Mellitus (T2DM)
Established cardiovascular disease (angina, coronary artery disease, heart failure, cerebrovascular disease, peripheral vascular disease)
Severe functional disability where social and everyday functioning is affected and where weight loss will contribute to a significant improvement, as outlined in the Severe Disability Group (SDG) ^7*

Phase 3: ≥TWO of the following conditions, which could be improved by weight loss:

Chronic kidney disease (stages 3 or 4)
Dyslipidaemia
Hidradenitis suppurativa or psoriasis
Hypertension
Idiopathic Intracranial Hypertension (IIH)
Metabolic dysfunction-associated steatohepatitis (MASH)^6*
Mild obstructive sleep apnoea (OSA)
Osteoarthritis
Polycystic Ovary Syndrome (PCOS)
Pre-diabetes/NDH or Type 2 Diabetes Mellitus (T2DM)
Established cardiovascular disease (angina, coronary artery disease, heart failure, cerebrovascular disease, peripheral vascular disease)
Severe functional disability where social and everyday functioning is affected and where weight loss will contribute to a significant improvement, as outlined in the Severe Disability Group (SDG)^7*

Phase 4

All other eligible patients as defined in NG246.

^1*NICE NG246: Overweight and obesity management – Referring adults to specialist services

Referral to specialist overweight and obesity management services if:

the underlying causes of overweight or obesity need to be assessed.
the person has complex disease states or needs that cannot be managed adequately in behavioural overweight and obesity management services (for example, the extra support needs of people with learning disabilities).
less intensive management has been unsuccessful.
specialist interventions (such as a very-low-calorie diet) may be needed.
surgery or certain medicines is being considered.

^2*Guidance for the phased introduction of new medical therapies for weight management: A joint position statement by the Society for Endocrinology and Obesity Management Collaborative UK (Dec 2023) https://www.omc-uk.org/sites/default/files/2024-01/2023-12-Joint-Position-Statement-on-Medical-Therapies-for-Obesity.pdf NB: this position statement is currently being revised following the Technology Appraisal for tirzepatide (Mounjaro®) therefore may be subject to change. Policy will be reviewed in light of any changes proposed.

^3*Contraception is required while taking semaglutide (Wegovy®) ahead of planned assisted conception.

^4*People with SMI, and people with LD, are at particularly high risk for cardiometabolic disease and premature mortality, and for this reason, should be considered as having greater priority and fall into the phase above where they meet the eligibility criteria.

NHS England » Learning from lives and deaths – People with a learning disability and autistic people (LeDeR)

Premature mortality in adults with severe mental illness (SMI) – GOV.UK

^5* At point of exiting paediatric services, some young people may already be using obesity medications and will need ongoing support, and review of their management. Many young people under the age of 18 and at high risk of complications from severe obesity may not have been able to access specialist weight management services or obesity medications. Additionally, young adults between the ages of 18 and 25 years may not yet have developed multiple complications to prioritise their entry to adult services. However, obesity at a young age poses a significant lifetime risk to health and compromise to education and future employment. For this reason, young adults presenting with weight-related comorbidities should be prioritised at a lower clinical threshold.

^6*There has been recent change in the nomenclature in liver diseases related to fat accumulation. All people with evidence of metabolic liver disease due to fat accumulation should be encouraged to lose weight. Those with the more serious form of Non-Alcoholic Fatty Liver Disease (NAFLD), previously known as Non-Alcoholic Steatohepatitis (NASH) but now known as Metabolic-associated steatohepatitis (MASH) can be referred

^7*Examples of social and everyday functioning that might be affected, as outlined in https://www.gov.uk/government/publications/severe-disability-group-test-information-for-clinicians/severe-disability-group-test-information-for-clinicians:
Requires assistance from another person to:

get in and out of bed
rise, sit and stand
prepare and cook food
eat and drink
take medication
wash and bathe
toilet
dress and undress
communicate and engage with others
manage finances and shop
leave the house and get around outdoors
maintain hygiene
plan and complete activities
cope with change
be aware of danger

Exclusions:

Under the age of 18
Pregnant or breastfeeding
Palliative care / end of life
Service users with severe active eating disorders.
Service users with unstable serious mental illness which prevents engagement with interventions provided. Once the condition is stabilised and the patient is well enough referral can be considered (see inclusion criteria in phase 1).
Have been previously referred into the service and have left the pathway early or have disengaged from the services, who are seeking to re-enter as a re-referral will not be eligible within 24 months.

Are unwilling to participate fully and comply with the weight management service