Consultant/Service to Whom Referral Will Be Made

Patient name:……………………………………………………………………………….

Address:…………………………………………………………………………………………………..

Date of birth:…………………………………………………………………………………………………..

NHS number:…………………………………………………………………………………………………..

Consultant/service to whom referral will be made:……………………………………………………………..

Hospital:…………………………………………………………………………………………………..

T18a Hip Replacement

Instructions for use:

To GP’s: Please refer to the above policy, complete the form and send it to the hospital consultant

To Consultants: Please complete the box below and file for future compliance audit.

The NHS Suffolk (Suffolk PCT) will only fund hip replacement for osteoarthritis if the following criteria have been met: / Please tick
if criteria met
BMI ≤35 AND EITHER /
Intense to severe persistent pain (defined in table one) which leads to severe functional limitations (defined in table two), OR /
Minor or moderate functional limitation (defined in table two) affecting the patients quality of life despite 6 months of conservative measures* /

If clinician considers need for referral/treatment on clinical grounds outside of these criteria, please refer to NHS Suffolk’s Individual funding request policy for further information.

*Conservative measures = Weight reduction, oral / topical NSAIDs and paracetamol based analgesics and patient education (e.g. activity / lifestyle modification).

Table 1: Classification of pain level

Pain Level
Slight / Sporadic pain.
Pain when climbing/descending stairs.
Allows daily activities to be carried out (those requiring great physical activity may be limited).
Medication, aspirin, paracetamol or NSAIDs to control pain with no/few side effects.
Moderate / Occasional pain.
Pain when walking on level surfaces (half an hour, or standing).
Some limitation of daily activities.
Medication, aspirin, paracetamol or NSAIDs to control with no/few side effects.
Intense / Pain of almost continuous nature.
Pain when walking short distances on level surfaces or standing for less than half an hour.
Daily activities significantly limited.
Continuous use of NSAIDs for treatment to take effect.
Requires the sporadic use of support systems walking stick, crutches).
Severe / Continuous pain.
Pain when resting.
Daily activities significantly limited constantly.
Continuous use of analgesics - narcotics/NSAIDs with adverse effects or no response.
Requires more constant use of support systems (walking stick, crutches).

Table two: Functional Limitations

Functional limitations
Minor / Functional capacity adequate to conduct normal activities and self care
Walking capacity of more than one hour
No aids needed
Moderate / Functional capacity adequate to perform only a few or none of the normal
activities and self care
Walking capacity of about one half hour
Aids such as a cane are needed
Severe / Largely or wholly incapacitated
Walking capacity of less than half hour or unable to walk or bedridden
Aids such as a cane, a walker or a wheelchair are required
If the above criteria are not met, does the patient meet the following exceptions: / Please tick
if criteria met
Patients whose pain is so severe and/or mobility is compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this. /
Patients whom the destruction of their joint is of such severity that delaying surgical correction would increase the technical difficulties of the procedure. /
Consultant use only
Please complete the following and file for future compliance audit.
Referral criteria is met and
the patient will benefit from
the proposed treatment: yes / no
Signature………………………………….
Consultant name: ……………………….
Please print
Hospital:……………………………… / GP use only
Practice stamp/address
Referring clinician: ……………………..
Date: …………………………………….. / Commissioner’s use only
Criteria met as per policy:yes / no
Compliance with notes:yes / no
Audit date: …………………………………
Audited by: ………………………………..
Please print
(GP/Cons)

If you have any queries about this form please contact 01473 770128