Quality statement 2: Discussion on the choice of interventions

Quality statement

Adults with a BMI of 30 or more for whom tier 2 interventions have been unsuccessful have a discussion about the choice of alternative interventions for weight management, including tier 3 services.

Rationale

People who have not benefited from tier 2 interventions should have a discussion with their healthcare professional about the options available. This can include tier 3 services, or equivalent, which provide specialist multidisciplinary team assessment and interventions. The choice of intervention should be agreed with the individual.

Quality measures

Structure

Evidence of local arrangements and written protocols to ensure that adults with a BMI of 30 or more for whom tier 2 interventions have been unsuccessful have a discussion about the choice of alternative interventions for weight management, including tier 3 services.

Data source: Local data collection.

Process

Proportion of adults with a BMI of 30 or more for whom tier 2 interventions have been unsuccessful who have a discussion about the choice of alternative interventions for weight management, including tier 3 services.

Numerator – the number in the denominator who have a discussion about the choice of alternative interventions for weight management, including tier 3 services.

Denominator – the number of adults with a BMI of 30 or more for whom tier 2 interventions have been unsuccessful.

Data source: Local data collection.

Outcome

Patient satisfaction with knowing the full range of choices on offer.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary, community and secondary care) ensure that they have a choice of interventions available for people for whom tier 2 services have been unsuccessful. This includes agreed pathways for referral to tier 3 services, or equivalent, and awareness among healthcare professionals of the criteria for referral to these services and how to make a referral if the person agrees.

Healthcare professionals ensure that they have a discussion with adults who have a BMI of 30 or more for whom tier 2 interventions have been unsuccessful about their choice of alternative interventions for weight management, including tier 3 services. Healthcare professionals ensure that they emphasise to the person that this should not be seen as a failure on their part, but that it represents another treatment option that may be appropriate for them.

Commissioners (clinical commissioning groups) ensure that they commission locally available tier 3 services, or equivalent, and that there are agreed pathways for referral to these services.

What the quality statement means for patients and carers

Adults whose body mass index (a measure of height and weight, often shortened to BMI) is 30 or more have a discussion with their healthcare professional about the choice of other services for weight loss that are available, such as a weight-loss clinic, if they have not been able to lose weight through dieting or weight-loss programmes.

Source guidance

Definitions of terms used in this quality statement

BMI

BMI is calculated by dividing weight (in kilograms) by the square of height (in metres).

[Adapted from Obesity: identification, assessment and management (NICE guideline CG189), recommendation 1.2.12]

Tier 2 services

Although local definitions vary, lifestyle weight management programmes are usually called tier 2 services.

Lifestyle weight management programmes for overweight or obese people are multicomponent programmes that aim to reduce a person's energy intake and help them to be more physically active by changing their behaviour. They may include weight management programmes, courses or clubs that:

  • accept people through self-referral or referral from a health or social care practitioner

  • are provided by the public, private or voluntary sector

  • are based in the community, workplaces, primary care or online.

[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53)]

Tier 3 service

NHS England and Public Health England's report Joined up clinical pathways for obesity and the Royal College of Surgeons' report Weight assessment and management clinics (tier 3) provide details on the composition of tier 3 services and activities.

If tier 3 services are not currently commissioned or available, support and assessment can be provided by equivalent services until tier 3 services become available. For example, medical assessment can be done in a tier 4 service if properly configured with a full multidisciplinary team that includes a doctor.

[Adapted from Obesity: identification, assessment and management (NICE guideline CG189)]

Unsuccessful interventions

Elements of such interventions may include:

  • previous attempts to lose weight

  • long history of cyclical weight loss and regain

  • person not ready to participate in a weight management programme

  • interventions that were not appropriate to the person's needs.

[Adapted from Royal College of Surgeons' report Weight assessment and management clinics (tier 3) and expert opinion]

Equality and diversity considerations

Some population groups, such as people of Asian family origin, have comorbidity risk factors that are of concern at different BMIs. Clinical judgement is needed when considering whether to refer to tier 3 services at lower BMI values.

People with learning disabilities may have different cognitive and social needs from the general population. Tier 3 services should be made accessible to address these needs.