Table 1.

Summary of the tiered weight management system in England

Tiers	Description	Location	Commissioning lead (primary responsibility agency)	Referral criteria	Patient journey—what are the characteristics of
1 Behavioural	Universal interventions (prevention and reinforcement of healthy eating and physical activity messages). Includes public health and national campaigns. Brief advice	Various	Local authorities responsible for the provision of community-based interventions which encourage healthy eating and physical activity		Overweight. Exit to either tier 2 or exit from pathway
2 Weight management services	Lifestyle weight management services. Normally time limited	Community/GP practice	Local authorities responsible for commissioning lifestyle weight management services. Local authorities as lead agency engaging CCG’s and NHS	Locally determined	Individual defined as having overweight and needs personal directed intervention/s in the community. Entry either self-referred or referred, possibly from tier 1. Exit from pathway. Continuation with tier 2 services. Exit to tier 3
3 Clinician led multidisciplinary team (MDT).	An MDT clinically led team approach, potentially including physician (including consultant or GP with a special interest), specialist nurse, specialist dietitian, psychologist, psychiatrist and physiotherapist	Location flexible—hub/community/GP practice/secondary care setting	CCGs as the future primary commissioners for tier 3 services, engaging with LA and NHS	BMI ≥ 35 kg/m2 with co-morbidities or ≥ 40	A person with obesity with complex needs who has not responded to previous tier interventions. Engagement in tier 3 does not automatically lead to surgery. Entry from either tier 2 or tier 4 or direct entry. Exit to either tier 2 or tier 4 or exit from pathway
4 Surgical and non-surgical	Bariatric surgery, supported by MDT pre- and post-op		NHS England is responsible for the assessment and provision of surgery in the short term. In recognizing the benefits of integrated commissioning, NHS England to conduct an early consideration of the elements of tier 4 that should transfer to CCG commissioning in the medium term	BMI ≥ 35 kg/m2 with co-morbidities or ≥ 40	Entry must have engaged with tier 3. Exit to tier 3 (post-op support)

CCG clinical commissioning groups. Tier 4 is currently funded by the CCGs not NHS England. At the time of the writing of this table, bariatric surgery was funded by NHS England. Adapted from [16]