HNY Central Digital Repository - York

Adult Obesity

The ICB will allow referral of an adult patient for Tier 4 Bariatric Surgery only where a patient meets the following conditions in line with Evidence Based Interventions wave 3 and NICE Guidance.

Direct Referral to Tier 4 is allowed if:

• BMI has been > 50 for at least 5 years, OR BMI has been > 45 with evidence of poorly controlled significant type 2 DM (based on medication and IFCC levels) But they will require at least 6 months Tier 3 or equivalent support to prepare for surgery as directed by the Acute Bariatric service.

All other referrals should meet the criteria as set out below and be progressed via a Tier 3 or equivalent service.

Evidence Based Intervention and NICE guidance states that surgery for obesity is an option if specific criteria are met, balancing the risk of surgery with the long-term impacts of no longer living with obesity.

Evidence shows that when commissioned as recommended, surgery is highly effective in causing weight loss, reduces the longterm impact of poor health and reduces the risk of premature death from obesity-related conditions.

Clinical overview

This establishes criteria for referral of an adult patient to a bariatric surgical centre for consideration of performing a bariatric surgical procedure.

For patients with a BMI of 50 and over, surgery may be considered as a first-line treatment intervention. This would mean a direct referral to the Acute provider; however, Acute pathways require at least 6 months on Tier 3 to prepare a patient for the consequences of surgery.

Clinical Referral Criteria for patients

A patient should be referred for consideration of bariatric surgery if they meet the following criteria and must meet all the additional “AND” criteria to be accepted for NHS Treatment.

The patient has:

• a BMI of 40 kg/m2 or more
• OR a BMI of between 35 kg/m2 and 40 kg/m with significant obesity-related complications likely to improve with weight loss (for example, type 2 diabetes, sleep apnoea or hypertension)
• OR a BMI of 30 kg/m2 or more with type 2 diabetes of less than 10 years duration
• OR the patient is of BAME family origin AND has recentonset type 2 diabetes AND a BMI of 28 or above

AND all the below criteria are met:

• Appropriate non-surgical measures have been tried but the patient has not achieved or maintained adequate, clinically beneficial weight loss
• The patient has been receiving or will receive intensive management in a tier 3 service or equivalent
• The patient commits to long-term follow-up

Additional to the clinical criteria set out above, the Bariatric Service, surgeon and anesthetist will consider and may reject a referral based on,

• The patient fitness for anesthesia and surgery
• The patient and clinician undertaking appropriate shared decision-making consultation regarding undergoing surgery including discussion of risks and benefits of surgical intervention.
   

Tier 4 Adult Bariatric Follow up and GP support

NHS patients who have had bariatric surgery will be followed up as standard for 2 years by the NHS Trust carrying out the operation (unless otherwise requested by the patient or Tier 4 MDT). Patients are seen clinically 4 monthly during the 1st year, and 6 monthly in the 2nd year. The NHS Service will monitor for excessive weight loss or anaemia, checking compliance with dietary advice and supplements and providing pregnancy counselling for women of child-bearing age.

After 2 years

Patients will be discharged from Acute care follow up. Care will pass to the registered GP and patients should be followed up as per the RCGP advice (link highlighted below) Those who have had a malabsorptive procedure (e.g., gastric bypass, gastric sleeve, duodenal switch) need annual screening for micronutrient deficiencies and lifelong prescriptions of certain key supplements. 3 This is detailed in national and local guidelines documents referenced at the end of this policy

Private patients not funded by the NHS

Private patients who have had their surgery in the UK should be receiving the same 2 year follow up from their surgical provider as NHS patients; GP’s may receive communication from the private provider, but care should remain with the private provider until the 2-year point and clinical responsibility should not be attempted to be passed to the NHS. This is not core work and the GP surgery are able to decline.

Private patients who have had surgery abroad

On the NHS pathway, the pre-op advice in a Tier 3 service process is a yearlong for good reason. Short term fixes that only provide the surgery are much less successful. The most immediate medical need for this group of patients is the recognition of complications such as late leaks or internal hernias. These present with continuous vomiting, dysphagia, intestinal obstruction, or severe abdominal pain and require emergency admission.

The patient's history should be flagged, and the bariatric team would see them and manage them acutely.

NHS bariatric services are not able to provide routine follow up to patients. These patients should be advised to seek a private bariatric follow up programme in the UK for a two-year period – these are available, and many accept self-referrals.

After the 2-year period the monitoring process is the same as for any other patient and the above guidelines should be followed

https://discovery.ucl.ac.uk/id/eprint/10108215/1/O'Kane

HEY1118-2020-Post-Discharge-Bariatric.pdf

http://www.rcgp.org.uk/clinical-and-research/a-to-z-clinicalresources/nutrition/~/media/Files/CIRC/Nutrition/Obesity/RCGPTop-ten-tips-for-post-bariatric-surgery-patients-in-primary-careNov-2014.ashx