Tier 4 Specialised Weight Management, Including Bariatric Surgery, Referral Criteria

Tier 4 Specialised Weight Management, including Bariatric Surgery, Referral Criteria

Morbid Obesity

Surgery for morbid obesity is not a first line service for patients with a BMI of less than 50kg/m2. The GP must be satisfied, and provide evidence, that all avenues of non-surgical management have been pursued and that the patient has not been able to lose weight using conventional weight loss programmes or referral to Dietetic or Psychotherapy services as appropriate. (please see the eligibility criteria below)

Bariatric Surgery is carried out by the NHS only at centres commissioned to provide Specialised Weight Management Services. Referral to one of these services does not mean that the patient is being referred for surgery, however surgery is a potential outcome following assessment and further non-surgical treatment if required.

Eligibility Criteria for patients (please note that these criteria must all be fulfilled)

1. The patient’s age is 18 years or over at the point of referral, and

2. The patient’s BMI is greater than 35kg/m2 but less than 40kg/m2 with co-morbidities that would be improved by losing weight. Co-morbidities include:

a. Established ischæmic heart disease

b. Type 2 diabetes requiring oral medication or insulin

c. Life-threatening sleep apnoea

d. Severe uncontrolled hypertension

e. Benign intracranial hypertension

f. History of transient ischæmic attacks or stroke

g. Severe lower limb major joint disease requiring orthopaedic intervention which is precluded on safety grounds due to patient's BMI

h. Other co-morbid condition which has been agreed by the PCT as exceptional, on an individual patient basis,

3. or, the patient’s BMI is greater than 40kg/m2 with or without obesity related co-morbidities, and

4. The patient has tried to lose weight over the course of 1 recent full year (ie a continuous 12 month period that ceases at the point of referral), without success. This includes but is not restricted to:

Weight management programme under the supervision of a dietician or GP or membership of a weight loss organisation, with evidence that a programme has been followed over a 12 month period without successful weight reduction.

5.and, it is imperative that the patient has received support from their GP throughout this non-surgical management phase and that there is evidence of the patient’s attendance of weight loss programmes, including drug therapy [1]. The weight loss programmes do not have to be provided by the NHS.

[1] Specialised Services Definitions state that drug treatment of obesity should follow at least three month’s supervised diet

Before a patient referral is made to a Specialised Weight Management service

Surgery for morbid obesity is not a first line service for patients with a BMI of less than 50kg/m2. The GP must be satisfied, and provide evidence, that all avenues of non-surgical management have been pursued and that the patient has not been able to lose weight using conventional weight loss programmes. (please see the eligibility criteria on page 1)

The GP should also ensure that any underlying psychological problems, which have contributed to the patient’s weight gain, are being managed appropriately including referral to local Mental Health services.

The GP must make the patient aware of the consequences and risks of morbid obesity surgery, such as:

- The dangers of any surgery for a morbidly obese patient, including death

- Large skin flaps as a consequence of rapid weight loss

- That plastic surgery to reduce excess skin is not funded by the local health economy unless there are exceptional health reasons for this surgery

- Although complications are not common, around 2 in 1,000 patients need revisions, therefore patients need to be aware of the risk of complications

The GP is confident that the patient is psychologically able to tolerate the long term side effects and understands that surgery is not a cure for obesity or an alternative to weight management but forms only part of the weight loss process. The GP should be satisfied that the patient will follow required dietary advice after the surgery has been completed.

GPs should complete the bariatric surgery approval form in full and send it to NHS Surrey. If more information is required the GP will be contacted by NHS Surrey. If this form is not completed fully it will be returned to the GP. Please do not send a referral letter to the provider until authorisation has been approved.

Patients must be told that authorisation has to be obtained before a referral can be made.

GPs will be notified if a patient is not approved and the reason why. If the referral does not clearly document non-surgical weight loss the application will be declined.

After Surgery Care

If surgery is carried out, the bariatric surgery provider will follow-up the patient post-surgery for as long as is required for the individual needs of the patient. This will include adjustments to gastric bands, dietetic support etc. Although initially this will be undertaken by the bariatric surgery provider in the longer term GPs will need to support patients post surgery.

Preferred Providers

The list of preferred providers is those that meet the South East Coast specification for a specialised weight management service. GPs need to discuss the alternatives with the patient. Please indicate preferred provider on the form, and be aware when discussing patient choice that Ashford and St Peters and St George's provide a combined service, as do Guy's and King's. Please note that provider waiting lists do vary.

Tier 4 Specialised Weight Management (Inc Bariatric Surgery) - Funding Application

Please read the notes on pages 1 and 2, and then complete all sections

The patient is aware that this application is for Specialised Weight Management Services that will include assessment and potentially further non-surgical treatment before bariatric surgery is considered. (please tick box) ( )

The patient is aware that SEC PCT’s do not routinely fund skin reduction surgery following weight loss. (please tick box) ( )

The patient is aware that a referral to a Specialised Weight Management Service cannot be made until authorisation of funding has been received from NHS Surrey. (please tick box) ( )

Patient details

Date of birthDay: Month: Year: Age:

NHS Number:

Ethnic Background:

Current height: m. Current Weight: kg. BMI: kg/m²

Date height/weight measurement taken:

Clinical criteria for consideration for surgery

If the patient's BMI is 35 kg/m² - 40 kg/m², does the patient have any of the following (tick ALL that apply):

Established ischæmic heart disease( )

Type 2 diabetes requiring oral medication or insulin( )

Life threatening sleep apnoea( )

Severe uncontrolled hypertension( )

History of TIA or stroke( )

Severe lower limb major joint disease requiring orthopaedic intervention which is precluded on safety grounds due to the patients BMI ( )

Other, please specify:

Does the patient have any specific psychological reason why the surgery may not be performed? Y* / N

Is the patient (in your opinion) fit to have a general anaesthetic?Y / N

Have you discussed the need for long term follow up with the patient? Y / N

(* please provide details)

Please give any further information you feel will be important in determining funding for this case, for example exceptional circumstances. Please enclose additional sheets if necessary.

Weight loss history

Non-surgical interventions

Please list the types and dates of weightloss programmes participated in. The patient must have tried and failed to maintain weight loss over a recent, continuous, 12 month period using weight reduction programmes:

1Start Date:End Date:Weight Loss:

2Start Date:End Date:Weight Loss:

3Start Date:End Date:Weight Loss:

4Start Date:End Date:Weight Loss:

Pharmacotherapy

Please list the weight loss drug therapies tried, where appropriate. Specialised Services Definitions state that drug treatment of obesity should follow at least three month’s continuous diet modification and monitoring:

1Date:Weight Loss:

2Date:Weight Loss:

3Date:Weight Loss:

4Date:Weight Loss:

Please list the four most recent BMI recordings, and the dates taken - these must be taken within the last year before referral:

BMI Reading 1BMI:Date:

BMI Reading 2BMI:Date:

BMI Reading 3BMI:Date:

BMI Reading 4BMI:Date:

GP contact details

GP name and address:

Phone number:

Fax number:

Practice Code (e.g. H82000):

PCT name:

Signature:Print Name:

Date:

Please return to:

Acute Contracting (TNRF) Team, NHS Surrey

Pascal Place, Randalls Research Park

Randalls Way, Leatherhead

Surrey, KT22 7TW

Or Safe Haven Fax: 01372 202690

NHS Surrey approval section

Date received: Date of Decision:

NHS Surrey Unique Identifier:

Decision:

Approved for assessment only (inc. investigations)( )

Approved for treatment plan and surgery( )

Approved for follow-up only (inc. investigations)( )

Not approved( )

Reason:

Approved by:Date:

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