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April 2010
Dear GP
Please find enclosed the new proforma to meet the latest East Midlands Specialised
Commissioning Group Policy for Access to Bariatric Surgery. As from 1st April 2009, all
referrals should now meet the new criteria. Specifically, the BMI limits of 50 kg/m2 or more,
or 45-50 kg/m2 in the presence of a serious co-morbidity which may be amenable to
treatment if obesity is modified by surgery.
Since it’s inception in 2004, the regional service in Derby has grown significantly to match
the unprecedented growth in referrals. The team at Derby now consists of Mr P Leeder,
Mr S Iftikhar, Mr J Ahmed and Mr A Awan, two radiologists, two nurse specialists and four
dieticians. Derby also now has an endocrinologist with a specialist interest in the medical
management of obesity, which is a service we also hope to develop over the next year.
The emphasis is on first and second line treatment in primary care, with surgery reserved
for those who are likely to benefit most. This is in keeping with NICE Clinical Guideline 43
on the prevention, identification, assessment and management of overweight and obesity
in adults and children (December 2006).
Please note that patients from Derbyshire County PCT now have to go through the
level 3 medical weight management service before they can be referred for bariatric
surgery. Failure to comply with such a service is associated with a poor outcome
with weight loss surgery.
If you experience any problems with the referral process or you require further clarification
on any aspect please contact, in the first instance, the relevant commissioner lead in your
Primary Care Trust.
Yours Sincerely
The Bariatric Team
Obesity surgery referral proforma V2.4
April 2010
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Specialised Commissioning Group Policy for Access to Bariatric
Surgery (for information)
Bariatric surgery is recommended as a treatment option for adults with obesity only if all
of the following criteria are fulfilled:
 BMI of 50 kg/m2 or more, or 45-50 kg/m2 with other significant disease (e.g. type 2
diabetes, hypertension) that could improve with weight loss
 Have been receiving and complied with weight management support, both medical
and psychological as required, in a specialised obesity hospital or a community
based equivalent
 Aged 18 years or over
 There is evidence that all appropriate and available non-surgical measures, which
may include commercially provided weight loss support programmes, have been
adequately tried for a period of a least 6 months but ideally 12 to 18 months but
has failed to maintain significant weight loss (i.e. ≥10%)
 There are no specific clinical or psychological contraindications to this type of
surgery and the individual is generally fit for anaesthesia and surgery
 Patients must be committed to the need for follow-up by a doctor and long-term
compliance with an altered lifestyle and dietary habit post-operatively
 Patients should not have smoked for at least 6 weeks before surgery
NICE Clinical Guideline 43. Obesity: guidance on the prevention, identification, assessment and
management of overweight and obesity in adults and children, December 2006.
Obesity surgery referral proforma V2.4
April 2010
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Regional Obesity Surgery Service Referral Form
Name:
Sex:
Date of Birth:
Age:
Address:
NB must be aged 18 or over
Postcode:
Telephone:
Mobile number:
NHS number:
GP Name:
Address:
Tel.No:
e-mail:
WE ARE NOT PERMITTED TO ACCEPT ANY
REFERRALS WITH INCOMPLETE INFORMATION
HEIGHT (metres)
WEIGHT (kg)
Actual not recall
Calculated BMI kg/m2
Must be >50 or
>45 with a co morbidity*
Date of measurements
*listed on page 5
EVIDENCE OF FAILURE TO LOSE WEIGHT OVER 6 MONTHS OR MORE
PREVIOUS WEIGHT (kg)
Actual not recall
DATE: ……………………………….
must be >6 months ago
CONFIRMATION OF NON-SMOKING STATUS.
We cannot accept patients who are currently smoking
NEVER SMOKED
CEASED SMOKING
Completely = 0/day
Obesity surgery referral proforma V2.4
DATE: ……………………………….
must be >6 weeks ago
April 2010
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EPWORTH SLEEPINESS SCALE
How likely is the patient to doze off or fall asleep in the following situations - in contrast to
just feeling tired? This refers to their usual way in recent times. Even if they have not
done some of these things recently, try to work out how they would have been affected.
Use the following scale to choose the most appropriate number for each situation
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Situation
Chance of
dozing
Sitting and reading
Watching television
Sitting inactively in a public place
Riding as a passenger in a car for one hour without a
break
Lying down to rest in the afternoon when circumstances
permit
Sitting and talking with someone
Sitting quietly after lunch without alcohol
Sitting in a car as the driver, while stopped for a few
minutes in traffic
Epworth Questionnaire Total Score
must be 10 or more, or the patient should have a history
of sleepiness in a dangerous situation.
PLEASE NOTE THAT IF A PATIENT SCORES > 10
THEN THEY MUST BE REFERRED FOR SLEEP
STUDIES BEFORE AN OBESITY REFERRAL IS
MADE.
Obesity surgery referral proforma V2.4
April 2010
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Sleep Apnoea Referral Criteria
(a minimum of 3 of the following criteria must apply
for referral)
Loud Snorer
Patient experiences waking with choking / obstructive
episodes
Patient’s working life severely affected by daytime
sleepiness
Patient’s driving severely affected by daytime sleepiness
Spouse has noticed episodes of stopping breathing
(although any snorer may experience such events,
especially when supine)
Regularly waking un-refreshed in the morning
Neck circumference over 17.5 inches (thus usually but not
always overweight)
Personality change, decreased libido, or nocturia
Sleep Apnoea syndrome
Snoring, paroxysmal waking with apnoea, excessive daytime sleepiness
If suspected must have a sleep clinic consultation prior to this referral
Non-sleep apnoea patients: Epworth screen score MUST be completed
appended to this proforma
Is the patient diagnosed with sleep apnoea?
If no go to bottom of this section
Does the patent use a CPAP mask?
must continue use in pre-op period
Has the patient trialled a CPAP mask?
if not tolerated, safe anaesthesia is unlikely
OR
Yes
No
Yes
No
Yes
No
Score
Epworth score and date calculated
Obesity surgery referral proforma V2.4
Date
April 2010
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Current Medication:
or append printout
Serious co-morbidities:
□ Type II Diabetes
□ Hypertension
□ Hyperlipidaemia
□ Cardio respiratory Disease
□ Other (please specify)
Relevant Past Medical History:
Blood Results and dates of recent investigations:
or append printout
Date:
Test:
HbA1C:
Diabetic/pre-diabetics
Glucose:
Fasting or Non-fasting? F NF
Na+
K+
Bilirubin
WCC
Urea
Creatinine
Alk.Phos
ALT
Hb
or AST
Plts
TSH (essential):
On thyroxine? Y N
T.Cholesterol:
HDL/LDL:
Triglycerides:
Obesity surgery referral proforma V2.4
April 2010
-7CONFIRMATION OF DIETETIC & BEHAVIOURAL INTERVENTIONS

Describe efforts to lose weight by dieting, which must include consultation with a
registered dietician. A dietician’s report would greatly assist.

Describe any efforts to lose weight by psychological therapy such as cognitive
behavioural therapy. A report or contact details would greatly assist if such a referral
has been made.

Describe efforts to lose weight using exercise as able. Describe current exercise
regimen. Has an exercise referral programme been trialled?
Specify
weight loss activity
Date and duration of
activity
Outcome
weight loss
State Registered
Dietician
Psychological
intervention
Exercise
schedule/programme
Other: please
specify
Comments:
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
Obesity surgery referral proforma V2.4
April 2010
-8CONFIRMATION OF FAILED MEDICAL THERAPY
All patients should have had an adequate trial of currently or previously available Oral antiobesity medication. Please provide details.
Weight reducing
medication
please ring - at
least one
If not, why not?
Duration of medication trial?
Effect of medication?
must complete > 3 months
approximate wt.loss
Currently Available:
Xenical
(orlistat)
Previously Available:
Reductil
(sibutramine)
Acomplia
(rimonabant)
Other
specify
Other possible contraindications - please confirm:
Physical contraindications to surgery, anaesthesia?
e.g. Class IV heart failure, home oxygen, unstable angina,
poor exercise tolerance, MI/CVA in previous 6 months
Yes
No
Confirm stable co-morbidity and optimised adequately
Yes
No
A Clinical Psychologist’s report is required for persisting anorexia
nervosa, bulimic symptoms or personality disorder (please
append)
Yes
No
A Psychiatrist’s report is required for bipolar or persisting severe
depression or schizophrenia (please append)
Yes
No
Obesity surgery referral proforma V2.4
April 2010
-9GP Signature:
Date:
THANKS FOR COMPLETING THIS REFERRAL
Please return completed pro forma to:
Surgical Outpatients, Royal Derby Hospital, Uttoxeter Road, Derby
DE22 3NE.
Telephone: Derby (01332) 787232
Obesity surgery referral proforma V2.4
April 2010