4. Criteria for commissioning
Bariatric surgery is a treatment for appropriate, selected patients with severe and complex obesity that has not responded to all other non-invasive therapies.
Within these patient groups bariatric surgery has been shown to be highly cost effective. Bariatric surgery is recommended by NICE as a first-line option for adults with a BMI of more than 50kg/m2, in whom surgical intervention is considered appropriate.
However, it will be required that these patients also fulfil the criteria below.
Selection criteria of patients for bariatric surgery should prevent perverse incentives for example patients should not become more eligible for surgery by increasing their body weight. Similarly the selection criteria should not forbid bariatric surgery for patients who have lost weight with non-surgical methods.
Eligibility for bariatric surgery
Surgery will only be considered as a treatment option for people with morbid obesity providing all of the following criteria are fulfilled:
The individual is considered morbidly obese. For the purpose of this policy bariatric surgery will be offered to adults with a BMI of 40kg/m2 or more, or between 35 kg/m2 and 40kg/m2 or greater in the presence of other significant diseases.
There must be formalised MDT led processes for the screening of co-morbidities and the detection of other significant diseases. These should include identification, diagnosis, severity/complexity assessment, risk
stratification/scoring and appropriate specialist referral for medical management. Such medical evaluation is mandatory prior to entering a surgical pathway.
Morbid/severe obesity has been present for at least five years.
The individual has recently received and complied with a local specialist obesity service weight loss programme (non surgical Tier 3 / 4), described as follows:
This will have been for duration of 12-24 months. For patients with BMI > 50
attending a specialist bariatric service, this period may include the stabilisation and assessment period prior to bariatric surgery. The minimum acceptable period is six months. The specialist obesity weight loss programme and MDT should be decided locally. This will be led by a professional with a specialist interest in obesity and include a physician, specialist dietician, nurse, psychologist and physical exercise therapist, all of whom must also have a specialist interest in obesity. There are different models of local MDT structure. Important features are the multidisciplinary, structured and organised approach, lead professional, assessment of evidence that all suitable non invasive options have been explored and trialled and individualised patient focus and targets. In addition to offering a programme of care the service will select and refer appropriate patients for consideration for bariatric surgery.
The non-surgical Tier 3 / 4 service may be community or hospital-based but will have as their role
Education
Dietary advice/support (which may be delivered through specialist obesity
dieticians, or slimming clubs – Weight Watchers, Slimming World etc.)
Enabling access to appropriate level of physical activity where not limited due to obesity related problems such as osteoarthritis, cardio respiratory disease
Exclusion of underlying contributory disease e.g. hypothyroidism, Cushing’s
Evaluation of co-morbidities (diabetes, sleep disorder breathing, etc) and
instigation of appropriate management plans
Evaluation of patient’s engagement with non-surgical measures
Evaluation of psychological factors relevant to obesity, eating behaviour, physical activity and patient engagement.
There is evidence of attendance, engagement and full participation in the above non surgical Tier 3 / 4 service Engagement can be judged by attendance records and achievement of pre-set individualised targets (for example steady and sustained weight loss of 5-10%, or maintaining constant weight whilst stopping smoking).
The patient has been assessed and referred by the lead physician/ clinician for the specialist obesity weight loss MDT.
The patient has been unable to lose clinically significant weight (i.e. enough to modify co-morbidities) during the period of intervention. Patients who lose sufficient weight to fall beneath the NICE guidance should not be considered appropriate for surgery.
The final decision on whether an operation is indicated should be made by the
specialist hospital bariatric MDT. For all bariatric surgery candidates, an individual risk benefit evaluation will be done by the Bariatric Surgery MDT, this will be informed by their own clinical assessment and information provided by primary care and by non-surgical Tier 3 / 4. In some locations there may be close liaison (and perhaps even overlap of personnel) between non-surgical Tier 3/4 and Bariatric
Surgery MDT. For example, a specialist bariatric physician would be on both MDTs.
The risk:benefit evaluation will consider:
Existing co-morbidities and their reversibility
Risk of future co-morbidities and their reversibility
Patients age and general level of health
Anticipated weight reduction
Alternatives if bariatric surgery is not undertaken
Peri-operative mortality
Post-operative complications of bariatric surgery
The Bariatric Surgery Team will satisfy itself that:
Bariatric surgery is in accordance with relevant guidelines
There are no specific clinical or psychological contraindications to this type of surgery
The individual is aged 18 years or above.
The patient has engaged with non-surgical Tier 3 / 4 Services.
The anaesthetic and other peri-operative risks have been appropriately
minimised
the patient has engaged in appropriate support or education groups/schemes to understand the benefits and risks of the intended surgical procedure
the patient is likely to engage in the follow up programme that is required after any bariatric surgical procedure to ensure
Safety of the patient,
Best clinical outcome is obtained and then maintained.
Change eating behaviour
Change physical behaviour as advised
The overall risk:benefit evaluation favours bariatric surgery
Revisional procedures will only be considered electively for clinical reasons due to complications and will require prior approval unless they are required on an acute emergency basis. (A separate policy will need to be developed for revisional procedures).
Any new/novel bariatric surgery procedures outside of this policy will not be routinely commissioned. Where a clinician wishes to make a request for a new
device/procedure, an application for exceptional funding through the NHS CB
Individual Funding Request (IFR) process should be made in the first instance.
The latter should be free to seek advice from the CRG leads. This request will then serve as an indicator for the CRG to undertake an evidence based review prior to developing a policy agreed by the CRG for the device/procedure requested.
