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Weight-loss surgery referral threshold lowered by NICE

Patients should no longer have to attempt weight loss by non-surgical interventions before referral to bariatric surgery, under new NICE guidance.

They also no longer have to be ‘generally fit for anaesthesia and surgery’ before referral to a specialist weight management service, which will instead undertake this assessment.

A new update to the clinical guideline for obesity identification, assessment and management removes a number of barriers for GPs to refer patients to be assessed for weight-loss surgery.

The previous guidance, first published nine years ago, had stipulated that referral for bariatric surgery should only be considered once ‘all appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss’.

But this has now been removed, alongside a requirement for the person to have gone through intensive weight management treatment in a Tier 3 service.

The new guideline instead uses the term ‘specialist weight management centre‘ – which requires the necessary expertise to assess patients but does not necessarily need to be tier 3.

Professor Alex Miras, professor of endocrinology at Ulster University, who participated in developing the new guidance, said: ‘If the team decide that the patient needs optimisation, this can take place before surgery is undertaken. If the team decide that there is no need for optimisation, then the patient can proceed to surgery much faster.’

The guidance also highlights that ‘drug treatments may be used to maintain or reduce weight before surgery for people who have been recommended surgery’.

And it further aims to clarify in which patents bariatric surgery interventions may be most beneficial.

Professor Miras said: ‘We have made it a bit more clear as to which obesity complications have a high level of evidence in terms of response to surgery (e.g. diabetes and fatty liver disease), while clarifying that the list is not exhaustive. In the previous guidance, the language used was more vague.’

GP referral criteria will also be subject to local commissioners, which may limit opportunities for bariatric surgery.

‘What we have done is make the patient’s journey towards bariatric surgery less cumbersome and removed some of the obstacles,’ said Professor Miras.

‘These changes may not necessarily increase the number of operations funded by the ICBs, but it will make the journey of the individual patient much more efficient.’

According to NICE, removing these barriers to referral will reduce variation in practice and increase uptake in previously overlooked groups.

‘This however does not mean more people will have bariatric surgery, because they may decide it is not right for them or they are not judged to be clinically suitable for surgery,’ a NICE spokesperson said.

Professor Azeem Majeed, a GP professor of primary care and public health at Imperial College London, said the new guideline ‘potentially has significant implications for general practices in England’.

He argued it will bring ‘additional work in discussing weight management with patients’ and that ‘suitable referral pathways would need to be in place with sufficient capacity to deal with an increase in patient numbers’.

This article was originally published by our sister publication Pulse.