NHS Dorset NHS Bournemouth and Poole NHS BOURNEMOUTH AND POOLE AND NHS DORSET BARIATRIC SURGERY POLICY NOTE Current funding priorities based on cost effectiveness enables funding of priorities 1, 2 and 3 only. Patients falling into priority 4 are unlikely to be funded and will not routinely be taken to the Individual Patient Treatment Panel for discussion. However, if the GP feels there are exceptional clinical circumstances and wishes for the case to go to Panel, then the GP may request this. Date: September 2010 Review Date: December 2011 Page 1 of 10
POLICY TRAIL AND VERSION CONTROL SHEET: Policy Reference: 01 BAR Version: 3 Approval Pan-Dorset Technologies Forum Distribution Intranet Website Other Date September 2010 Yes Yes GP s RBCH & PHFT Date of Issue Version No. Next Review Date Document History Date Approved Nature of Change Sept 2010 V3 Dec 2011 1.2 and 1.3 (new) explanatory text 2.2 (new) Introduction of prioritised list and change of access criteria for BMI and co morbidities 2.3 (new) explanatory text 4 (new) section on previous surgery Page 2 of 10
NHS BOURNEMOUTH AND POOLE AND NHS DORSET POLICY IN RELATION TO BARIATRIC SURGERY 1 INTRODUCTION 1.1 Bariatric surgery for patients assessed as being morbidly obese is a last resort to aid weight reduction. All other non surgical options must have been exhausted (with evidence recorded and presented) prior to approval being given to refer to secondary care for assessment for surgery. 1.2 Bariatric surgery is a specialist service and the Primary Care Trusts (PCTs) have been working with South West Specialist Commissioning Group to develop capacity within designated services. The designation process ensures that services have appropriately trained and experienced surgeons working within multidisciplinary specialist teams and an adequate caseload to maintain surgical skills and optimise outcomes. 1.3 In developing these services commissioners are implementing NICE guidance in a phased way over ten years, reflecting service capacity, local need and local commissioning priorities. 2 ACCESS CRITERIA 2.1 All patients referred for assessment for bariatric surgery must have: been actively supported by their GP in the community over an extended period of not less than three years; undertaken a programme of non-surgical measures including diet, exercise, lifestyle and promotion of health and wellbeing, before surgery is considered. Gradual results achieved by a change in lifestyle over a sustained period should be very strongly encouraged. 2.2 Patients who may be considered for bariatric surgery have been prioritised in four different groups. Whilst the service is developing and the level of need is still not fully understood the PCT can only support requests within current commissioned levels of activity, and may therefore have to set a threshold as to which groups are supported. The prioritised list of the four groups is: PRIORITY ONE: Patients with BMI over 40 who also have type 2 diabetes. These patients may have an increased mortality risk without surgery and there is good evidence to suggest that surgery might reduce this risk. PRIORITY TWO: Patients with BMI over 50 either with or without co-morbidities. This group is highlighted in the NICE guidance. Page 3 of 10
PRIORITY THREE: Patients with BMI over 40 who also have other significant medical conditions where there is evidence that these could be improved by bariatric surgery. Significant co-morbidity includes one or more of the following: established ischemic heart disease; severe uncontrolled hypertension; history of transient ischemic attacks or stroke; severe lower limb major joint disease requiring orthopaedic intervention which is precluded on safety grounds due to patients BMI; life threatening sleep apnoea; PRIORITY FOUR: Patients with BMI over 45 but with no co-morbidities. 2.3 Other groups of patients will not be considered for bariatric surgery during this phase of implementation. 2.4 The PCTs will make the level of commissioned activity for each financial year publicly available, including which groups of patients are likely to be prior approved for referral for assessment for bariatric surgery. 3 REFERRAL PATHWAY 3.1 GPs are already required to collect data on any patient with a BMI of 30 or more and offer lifestyle advice. 3.2 Examples of resources available in Dorset are set out at Appendix 1. 3.3 Other non surgical resources available to control obesity include: counselling; psychological assessment and programme; medication. 3.4 The GP practice of a patient identified as having morbid obesity should identify a health professional who will act as the advisor to each patient and who will assist in drawing up a specific programme of non surgical measures. Regular assessment should be undertaken to review progress. The GP practice will have supported the patient in co-ordinated way for at least three years prior to a request for surgery. 3.5 Patients will only be considered for referral to secondary care for consideration of surgery, if evidence is presented to demonstrate sustained and co-ordinated community programmes have failed. These measures must be documented to show what has been tried, the length of time, and reason for failure. Page 4 of 10
3.6 The documentation and evidence as set out in the bariatric surgery proforma (Appendix 2) should be submitted by the patient s GP to NHS Bournemouth and Poole or NHS Dorset for consideration against the criterion set out in the NICE guidance. It is the responsibility of the relevant health professional at the GP practice to complete the bariatric surgery proforma in full. 3.7 The potential benefits and longer-term implications of surgery, as well as the associated risks, including complications and postoperative mortality need to be fully understood by patients referred for potential surgery. 3.8 It should be noted that where cosmetic surgery is requested following weight loss this is not supported, in line with our policies for cosmetic surgery and abdominplasty. 3.9 NHS Bournemouth and Poole and NHS Dorset will consider applications only where full information is provided. If approval is given by the PCT for referral to secondary care, this will be to a multidisciplinary team which will include a specialist dietician; a dedicated nurse; a physician; a specialist surgeon; a specialist anaesthetist; a radiologist where appropriate; and a psychologist or psychiatrist if required. 3.10 Referral to secondary care should only be made following explicit approval by the Primary Care Trust following receipt and consideration of the evidence set out in Appendix 2. 3.11 The information that will be required from GPs with each referral is set out as Appendix 2. 4 PREVIOUS SURGERY 4.1 Where a patient has already undergone bariatric surgery and has failed to lose weight due to surgical complications, they may be considered for further surgery, (including, if appropriate, the use of a different surgical technique), if they continue to meet the access criteria as outlined in section 2 and this is deemed clinically appropriate. 4.2 Where a patient has previously reduced their BMI below the criteria outlined in section 2 through bariatric surgery, but has now regained weight repeat surgery may be supported if they once again meet the criteria and this is deemed clinically appropriate, bearing in mind the need for commitment to lifestyle changes that should occur alongside surgery to facilitate weight loss. 4.3 Where a patient has privately funded bariatric surgery and wishes to transfer to the NHS for routine follow up this will only be supported where the patient meets the current local access criteria for bariatric surgery at the time of their initial bariatric surgery. 5 REVIEW OF POLICY Version: This is Policy version 3.0 Agreed: September 2010 Review by: December 2011 References National Institute Of Health And Clinical Excellence Guidance (NICE) Clinical Guideline 43: Obesity; guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children, December 2006. Page 5 of 10
APPENDIX 1: CONTACT DETAILS FOR INITIATIVES IN DORSET WHICH SUPPORT WEIGHT LOSS (SUCH AS EXERCISE REFERRAL) Note that these initiatives may be specific to particular geographical areas Healthy Choices Weight management on referral Patient referral via health professional. Health professional can contact the referral hub for information and a copy of the referral form on 01305 765200 Bournemouth Littledown Centre 01202 417600 Christchurch Two Riversmeet Leisure Centre 01202 477987 Sturminster Newton Leisure Centre 01258 471831 Blandford Leisure Centre 01258 455566 Poole Borough Council/Poole Primary Care Trust 01202 261303 Purbeck Leisure Centre, Wareham 01929 556454 QE Leisure Centre, Wimborne (Way of Life Scheme) 01202 888677 Verwood Leisure Centre 01202 821007 Ferndown Leisure Centre 01202 877468 Oakdene Leisure Centre (St Leonards) 01202 875422 Activate 1000 Moors Valley (East Dorset) 01425 470721 West Dorset www.dorsetforyou.com 01305 252263 Healthy Living Wessex 01305 765204 Page 6 of 10
APPENDIX 2: BARIATRIC SURGERY PROFORMA This form must be completed for all Individual Treatment Requests for bariatric surgery referrals. Requests will not be considered without a completed form and the relevant supporting evidence. Handwritten submissions will not be accepted as these forms are forwarded to the providers. NHS NUMBER: PATIENT NAME: D.O.B.: PATIENT WEIGHT: At point of request: 3 months previously: 6 months previously: PATIENT HEIGHT: BMI: At point of request: 3 months previously: 6 months previously: PRACTICE NAME: DATE OF REQUEST The patient with morbid obesity considered for surgery for weight reduction meets all of the following criteria and evidence is presented to support all measures have been attempted to achieve weight loss. 1 2 3 EVIDENCE (documentation attached where relevant) CRITERION REQUIREMENTS / EXAMPLES including dates and reasons for failure. Please provide details of all actions, reasons for success or failure and alternative solutions to demonstrate that the patient has adequately tried all non-surgical measures to include lifestyle, exercise and diet evidenced as being supported by the GP practice for a period of not less than 3 years prior to the request for surgery. Please include relevant test results and drug interventions tried. Lifestyle programme Details of support team including GP, any other practice teams such as nurses, dietician and timescales of the in the community support programme to attempt weight loss. Details of co-ordinated programmes of lifestyle changes to promote health and wellbeing, these should have been agreed with the patient and progress recorded and improvements documented. This should include details of any exercise or onward referrals made. Diary of patient lifestyle at outset of any support programme and diary of patient lifestyle changes during and following the programme, in particular in the last 6 months. We would expect details of any non compliance to also be provided. Page 7 of 10
APPENDIX 2: BARIATRIC SURGERY PROFORMA NHS NUMBER: PATIENT NAME: D.O.B.: 4 5 6 CRITERION REQUIREMENTS / EXAMPLES EVIDENCE (documentation attached where relevant) including dates and reasons for failure. Details of progressive exercise programmes and outcomes. This should include weight and BMI Exercise Programme measurements at the start, during and after the with regular input programme. We would expect details of any non compliance to also be provided. Diet as part of lifestyle change Results of the patient s Endocrine screening including: [Test results where applicable and available] Details of diet changes made as part of the lifestyle change, this can include information from dieticians and a patient s food diary. These changes must have been in place for at least the last 6 months. Information of the impact of the diet changes to achieving weight loss should also be provided. Fasting plasma glucose Full blood count Urea and electrolytes liver function tests Thyroid function tests Lipid profile Dexamethasone suppression test Page 8 of 10
APPENDIX 2: BARIATRIC SURGERY PROFORMA NHS NUMBER: PATIENT NAME: D.O.B.: 7 CRITERION REQUIREMENTS / EXAMPLES EVIDENCE (documentation attached where relevant) including dates and reasons for failure. Details of any psychological programme and/or assessment the patient has received, this should include details of any specialist service or consultant involved. Psychological and assessment Does the patient have an underlying mental health programme issue that has contributed to their obesity? Please provide your assessment of the patient s psychological ability to adjust to the lifestyle changes required as a result of this surgery. 8 Cognitive behaviour therapy Details of any cognitive behaviour therapy the patient has received and the outcomes of that therapy and dates. 9 Drug intervention Details of drug interventions - this must include start and finish dates, weights at the start and finish, total weight loss, reasons intervention stopped including any side affects experienced. Page 9 of 10
APPENDIX 2: BARIATRIC SURGERY PROFORMA NHS NUMBER: PATIENT NAME: D.O.B.: Type II Diabetes 10 Co-morbidity and success in control of disease. Indicate whether the patient has any of these specified conditions, the impact on the patient and what therapy the patient is currently receiving Ischaemic heart disease Severe uncontrolled hypertension History of transient ischaemic attacks or stroke Severe lower limb major joint disease that requires intervention that cannot go ahead due to BMI Life threatening sleep apnoea 11 12 13 The patient has no specific clinical or psychological contraindications to the surgery. The patient is assessed as likely to be fit for anaesthesia and surgery The patient understands the need for long-term follow-up Please indicate whether the patient has any other co-morbidities that may relate to their BMI, how this impacts on the patient and what therapy the patient is currently receiving: As the patient s GP, please confirm if there are any specific clinical or psychological contra-indications that you are aware of. Please confirm if it is your opinion that the patient is likely to be fit. As the patient s GP, is it your opinion that the patient fully understands the implications of lifestyle changes, surgery and the need for long-term follow-up. Please sign and date to confirm this is the case. Page 10 of 10