As a direct result of the COVID-19 pandemic, and partly in response to an escalating crisis in the UK, NHSE has launched the Weight Management 21/22 DES. So, what are we required to do? First things first, if you want to be part of the DES, sign-up needs to be completed by 31^st July 2021.

As practices, you’ll need to keep a register of patients aged 18 and over with a BMI of 30 or over, recorded in the previous 12 months, or a BMI of 27.5 or over if the patients are in a Black, Asian or other minority ethnic group (BAME).

Your QOF register might not currently fit the bill for those with a BMI of under 30, so you may need to do more work to identify patients you should include. Achieving a register might be more difficult than you might imagine, given the move to more remote consultations, and this is directly addressed in the DES which notes that despite the increased risk from COVID-19 that comes with a higher BMI, practices are recording fewer patients with higher BMIs.

Importantly, if signing up, you’ll need to make sure you can restore your practice obesity register to at least its 30^thMarch 2020 recording level, where this is clinically suitable as well as practically and reasonably possible.

Weight can be a sensitive and highly charged subject for some patients, so the DES makes it really clear that those staff who are involved in referring or signposting patients must be suitably trained and skilled to have those discussions. The DES gives links to some really helpful resources for training and education.

In our recent Virtual Learning session with Bridin McKenna, we talked about the importance of checking with the patient if they’d be open to having a conversation about their weight.  This might be by asking something along the lines of “would it be OK to talk about your weight today?” or “how would you feel if we talked about your weight?”. For some patients, being given the option to say “I don’t want to talk about it” will make a difference to how they view the conversation. Bridin also talked about the huge importance of the language we use and the way that patients feel when healthcare professionals use terminology that they find unhelpful or stigmatising. Bridin spoke about the difficulties of generalising health outcomes for patients with higher BMIs, and the importance of treating every patient as an individual. For medical professionals involved in difficult conversations about weight, it will be important to remember that some patients skip regular medical appointments because they’re worried that they’ll feel shamed by a medical professional about their weight.

To fulfil the requirements of the DES, practices must develop an approach that supports and informs patients living with obesity. This will include the need to:

• Normalise discussions about weight in all consultations
• Recognise the sensitivity of the discussions and use shared decision-making
• Consider all opportunities to identify those living with obesity and how this can be managed both in practice and with the growth of online and remote consultations
• Encourage patients to provide the practice with self-reportable information about their health including their weight
• Ensure patients with a BMI that would indicate they’re living with obesity have an annual update to their BMI recorded
• Record and maintain information about weight management services and how you can refer patients to them

For patients who were recorded as living with obesity on 31^st March 2021 (on the QOF Obesity register), and those identified as living with obesity during this year (21/22), GPs should assess whether the patient is ready to engage with weight management services, and look to record BMI and refer patients to available services where appropriate. The Referral Choice Audit [PLUS] can be a useful tool to assist with decision making. There’s no minimum number of referrals, but patients’ willingness to engage is an integral part of the process. Referrals should be made by suitably trained and competent GP or PCN staff, and the following should be recorded in the patients’ health records:

1. Their informed consent to engage (or the consent of their representative, along with their relationship to the patient)
2. The referral itself
3. The sharing of relevant information

Patients who are willing to engage should be referred to the most clinically appropriate service. For patients with specific needs, or other health conditions, this may be to a specialist service. There are specific services that are considered appropriate for referral; these are:

• NHS Digital Weight Management services for those with hypertension and/or diabetes
• Local authority funding Tier 2 weight management services
• Diabetes Prevention Programme for those with non-diabetic hyperglycaemia
• Tier 3 or 4 weight management services

Discussions about weight and weight management don’t need to be part of a stand-alone consultation. The DES expects that weight and weight management should become a routine part of consultations, and many patients with comorbidities will be in contact with the practice on a regular basis for review.

Each practice will be notified of their minimum number of available referral allocations – that is, referrals available for the practice. This will be a minimum of one-third of the number of patients on the Obesity register on 31^st March 2020. Practices will be allocated a revised number of available referrals once the number of practices participating in the DES is clear; this revised figure will be notified to participating practices by 31^st August 2021.

Practices will be paid £11.50 per referral to one of the specified services, up to the limit of their referral allocation. Payment will be made for only one referral per patient and there is a specific code to use (referral to weight management service: 1326201000000101). To be eligible, patients MUST also have a BMI, recorded since 30^thMarch 2020, that is 30 or over or 27.5 or over for those who are BAME. Practices must make a manual claim to their commissioner. Claims should be made monthly, within 12 days of the end of the relevant period. Claims will be paid manually.

If by 30^th November 2021 a practice has achieved less than 40% of its total referrals, the commissioner may reduce the allocation available to the practice from January 2022. Conversely, where practices have used all of their total referral allocation, the commissioner may increase the total number of referrals available to the practice. By balancing the referrals between practices in this way, it should be possible to maximise the number of patients who are referred and use the services. Commissioners can choose to waive the referral allocation mechanism, with any excess referral funding being met from existing local commissioner funds.

Having listened to the Virtual Learning session with Bridin, it’s clear that those practices that can strike a balance between the requirements of the DES and the need for patients to feel valued and listened to, may end up having really productive conversations about weight and a high success rate for referrals.