The Oxford Bariatric Service (OBS) Referral

NICE Clinical Guideline 43: Obesity defines morbid obesity as people with:

  • Body mass index (BMI) ≥40 kg/m2
  • Or BMI between 35 - 40 kg/m2and other significant co-morbidity (e.g. diabetes, high blood pressure) that may be improved if they lose weight.

NICE recommend that surgery to aid weight loss should be available as a treatment option for people with morbid obesity provided that they meet all of the following criteria.

Note: Bariatric surgery is recommended as a first line option for people with a BMI ≥50kg/m2 in whom surgical intervention is appropriate. The commissioning guidelines are available to review at:-

Criteria / Meets criteria?
(Y / N)
Aged 18 years or over
Morbid obesity present for 5 years or more
Has participated in a Tier 3 medical weight-loss programme (e.g. OWLS Oxfordshire Weight Loss & Lifestyle Service or Morelife) for 12 months or for 6 months if the patient has diabetes.
Tried all other appropriate non-surgical treatments to lose weight but has not been able to maintain weight loss e.g. diet, medication, counselling
No specific medical or psychological reasons why they should not have this type of surgery e.g. drug or alcohol dependency, binge eating disorder
Patient is aware of the requirement for follow up within the bariatric service for 2 years after surgery

Patient details

Name
Address / DOB
NHS number
Telephone
GP / GP telephone
GP address

Weight history

Most recent weight (kg) / Date of weight
Height (m) / BMI (kg/m2)
Please indicate the name of the Tier 3 service attended and the period of time spent in medical weight loss programme.
(The referral cannot be processed if this information is missing. Please note that Slimming World and Weight Watchers are not a Tier 3 service)

Medical History

Tick any medical conditions relevant to this individual and provide additional details.

Attach list of current medications if required.

Send any relevant letters of investigations e.g. cardiology or respiratory reviews.

Condition / Tick / Further information
Type 2 Diabetes / Insulin / tablet / diet treated
Medication & doses:
Type 1 Diabetes / Medication & doses
Heart disease / Medication:
Obstructive sleep apnoea
*See comment below / CPAP required / no formal sleep study
Epworth Score:
Stop bang:
High blood pressure / Medication:
Respiratory disease / Medication:
Polycycstic ovarian syndrome (PCOS) / Medication:
Dyslipideamia / Medication:
Arthritis / limited mobility / joint pain / Details:
Depression / anxiety / Details of treatment:
Allergies / Specific allergens:
Please indicate smoking status
**See comment below / Never / Ex-smoker /Currently smokes
***Please provide recent biochemistry and haematology blood results as listed. Referrals received without these results will encounter delays until we receive these results. / Electrolytes: Sodium, potassium, urea, creatinine, phosphate, magnesium, calcium, serum bicarbonate, glucose
Liver function test including GGT
Vitamin B12
Lipids: Total Cholesterol, LDL, HDL, Tg
HbA1c
TSH & FT4
Vitamin D
Red Cell Folate, Serum Ferritin, Total Iron Binding Capacity, Serum Iron, FBC
If Diabetic: Urinary Microalbumin to creatinine ratio(MACR)
Provide details of other relevant medical conditions:

Important Please Note:

*To avoid delays in this process please assess your patient for sleep apnoea if not already treated or recently assessed. Stop bang and Epworth charts can be accessed from the following website under online sleep tests (). If appropriate refer to the sleep clinic, all patients will require at least 6 weeks on CPAP prior to progressing for surgery.

**Unfortunately patients will not be offered surgery if they currently smoke, please advise your patient of appropriate cessation support if applicable.

***To avoid delays please ensure the appropriate blood results are attached to the referral form. This will enable the team to expedite referrals to the appropriate bariatric team member. You will be asked to send this information prior to your patient being seen in our assessment clinic if it is not included.

This referral has been discussed with the patient.
Appropriate referrals will be assessed by the Oxford Bariatric Surgery Team.
Signed / Date
Job title

Post:Lisa Francombe, Secretary, Surgical Admin, Level 0, Cancer Centre, Churchill Hospital, Oxford, OX3 7LE

Fax:FAO Lisa Francombe 01865 235857

Email:

Oxford Bariatric Service Referral Form October 2015