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.
2.
a.
b.
c.
d.
e.
f.
g.
h.
3.
4.
5.
The patient’s age is 18 years or over at the point of referral, and
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:
Established ischæmic heart disease
Type 2 diabetes requiring oral medication or insulin
Life-threatening sleep apnoea
Severe uncontrolled hypertension
Benign intracranial hypertension
History of transient ischæmic attacks or stroke
Severe lower limb major joint disease requiring orthopaedic intervention which is
precluded on safety grounds due to patient's BMI
Other co-morbid condition which has been agreed by the PCT as exceptional, on an
individual patient basis,
or, the patient’s BMI is greater than 40kg/m2 with or without obesity related comorbidities, and
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.
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
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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.
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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 birth
Day:
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
on safety grounds due to the patients BMI
(
)
)
)
)
)
precluded
)
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.
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Weight loss history
Non-surgical interventions
Please list the types and dates of weight loss 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:
1
2
3
4
Start
Start
Start
Start
Date:
Date:
Date:
Date:
End
End
End
End
Date:
Date:
Date:
Date:
Weight
Weight
Weight
Weight
Loss:
Loss:
Loss:
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:
1
2
3
4
Date:
Date:
Date:
Date:
Weight
Weight
Weight
Weight
Loss:
Loss:
Loss:
Loss:
Please list the four most recent BMI recordings, and the dates taken - these must be taken
within the last year before referral:
BMI
BMI
BMI
BMI
Reading
Reading
Reading
Reading
1
2
3
4
BMI:
BMI:
BMI:
BMI:
Date:
Date:
Date:
Date:
GP contact details
GP name and address:
Phone number:
Fax number:
Practice Code (e.g. H82000):
PCT name:
Signature:
Print Name:
Date:
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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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