Further to the launch of the pilot Tier 3 Obesity Management Service at York Teaching Hospital NHS Foundation Trust, all candidates for Tier 4 services (bariatric surgery) should be referred via Tier 3 in the first instance.  Where there are exceptional circumstances which may justify direct referral to Tier 4 services, an IFR application should be made.

• Tier 3 Obesity Management Service
• Bariatric Surgery Commissioning Statement
• Individual Funding Requests

Exclusions

Smoking

Patients to be listed for bariatric surgery who are smokers must stop smoking prior to being put on the waiting list. The patient can be placed on the waiting list once they have successfully stopped smoking for 8 weeks.

Commissioning position

Referral to tier 4 bariatric surgery

Bariatric surgery is not routinely commissioned, but referral to Tier 4 will be considered by the Tier 3 weight management programme (WMP) multi-disciplinary team (MDT) panel following completion of the Tier 3 WMP, for the most costeffective subgroups where the patient has a:

• BMI ≥50, OR
• BMI ≥45 with significant poorly controlled type 2 diabetes (based on medication and IFCC).

The Tier 3 MDT Panel will consider bariatric surgery as a treatment for selected patients with severe and complex obesity, where all of the following criteria have been met:

• the person has not responded to ALL other noninvasive therapies and is willing to have the surgery
• there is no specific clinical or psychological contraindications to this type of surgery
• the person is generally fit for anaesthesia and surgery, with assessment of peri-operative mortality and postoperative complications of bariatric surgery
• the person commits to long-term follow-up and dietary compliance and is considered likely to engage in the follow up programme that is required after any bariatric surgical procedure

Funding in all other circumstances will only be considered where there are exceptional clinical circumstances. The clinician needs to submit an application to the CCG’s Individual Funding Request Panel (IFR).

NB Referrers and patients should be aware of the following:

• Revision/re-do bariatric surgery

Vale of York CCG does NOT routinely commission revision/re-do surgery.

Revision or re-do surgery is commissioned for ‘urgent’ surgical reasons. Patients must be advised this as part of the informed consent process. Where there has been a surgical failure (e.g. slipped band) that is remediable relative easily.

Revision/re-do surgery is NOT routinely commissioned where there is failure to lose weight despite successful surgery. Where there is clinical exceptionality an application can be made for prior approval from IFR panel.

Any new/novel bariatric surgery procedures outside of this policy are not commissioned.

• Non-designated providers or private funding

Specialist post-operative and locality MDT weight management support will not be routinely funded for patients who have chosen to receive their bariatric surgery from a provider who is not a designated regional provider of morbid obesity surgical services or where surgery has been privately funded.

• Body contouring surgery

Body contouring surgery following substantial weight loss is not routinely commissioned.

---