This is an HTML version of an attachment to the Freedom of Information request 'Bariatric Surgery'.

The Quality Unit 
Planning and Quality Division 
T: 0131-244 2287 
NHSScotland Board Chief Executives 
NHSScotland Board Medical Directors 
NHSScotland Public Health Directors  
16 July 2012  
Dear Colleague 
1.  The purpose of this letter is to highlight to NHS Boards and primary and secondary care 
clinicians, the Best Practice Guide which has been developed for obesity treatment. 
2.  The National Planning Forum (NPF), a joint forum of Scottish Government and NHS 
Boards, was requested by the Scottish Government’s Preventing Overweight and 
Obesity - A Route Map Towards Healthy Weight (February 2010) 
to establish a 
subgroup to provide advice on treatments for  obesity. It was also agreed that surgical 
options should be placed in the wider context of weight management.   
3.  An Obesity Treatment Subgroup (OTS) was established by the NPF to set out options 
for a common approach to planning the provision of weight management services and 
surgical intervention for the treatment of people with severe and complex obesity. 
4.  The Subgroup recommendations were considered and approved by the NPF and a 
summary of the report was presented to NHS Board Chief Executives who also agreed 
that the recommendations should be taken forward. 
5.  A short life working group was formed to take forward the national recommendations on 
the basis of the extensive evidence reviews, a health inequalities impact assessment 
and expert clinical reports. These reports and the short life working group scoping 
reports are available from the NPF secretariat.  The  short life working group’s advice is: 
5.1 Agreed national care pathways need to be put in place for: 
•  Those patients with Type 2 diabetes who are age 18-44 years with a BMI 35-40 
kg/m2 and recent (less than 5 years) onset of their diabetes (Priority 1) 
St Andrew’s House, Regent Road, Edinburgh  EH1 3DG 
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•  Other groups of patients who, local clinicians, feel may benefit from bariatric 
5.2 There needs to be agreement concerning: 
•  Patient pathways from specialist weight management services into assessment for 
bariatric surgery, consideration of surgical procedures and follow up after surgery 
•  Assessment of patients who do not fulfil the criteria agreed by NPF through the 
use of local Board review panels for individual cases  
•  Provision of clinical and cost effectiveness outcome data on all bariatric 
6.  There were also regional recommendations which are being taken forward in parallel 
with the national recommendations and will also be informed by them.  These are 
detailed below: 
•  Boards should work within regional planning groups to review centres within regions 
and consider existing services against the new criteria for surgical centres 
•  Boards should work within regional obesity groups to agree phased increased 
capacity over the next few years 
•  Boards should work within regional planning groups to review the level of Tier 3 
provision and explore opportunities for cross board collaboration 
Development of the Good Practice Guidance 
7.  The Best Practice Guidance has been developed by a short life working group chaired 
by Heather Knox and Dr Jennifer Armstrong, Senior Medical Officer with a multi-
disciplinary group of experts (see Appendix A).  It is based on the best available 
8.  The Guidance covers: 
1.  Patient Pathway From Specialist Weight Management Services Into Assessment 
For Bariatric Surgery 
2. Surgical 
3.  Assessment Of Patients Who Do Not Fulfil The Criteria 
4. Clinical 
5. Follow 
Protocols Following Surgery 
Yours sincerely 
Ms Heather Knox 
Regional Planning Director  
National Planning Forum member 
Dr Sara Davies  
Consultant Public Health Medicine  
Scottish Government Health and Social Care 


Best Practice Guide 
Publication date: July 2012 

The National Planning Forum (NPF) was requested by the Scottish 
Government’s  Preventing Overweight and Obesity - A Route Map 
Towards Healthy Weight (February 2010) 
to establish a subgroup to 
provide advice on treatments for obesity. It was also agreed that 
surgical options should be placed in the wider context of weight 

This Best Practice Guidance is the result of the work undertaken by the 
1.  Patient Pathway From Specialist Weight Management Services Into 

Assessment For Bariatric Surgery 
2. Surgical Procedures 
3.  Assessment Of Patients Who Do Not Fulfil The Criteria 
4.  Clinical Outcomes – Collection Of Data 
5.  Follow Up Protocols Following Surgery 
Strategic Approach 
The evidence for obesity treatment is growing and currently suggests a tiered 
health service is the most effective for population planning.  The tiers are 
usually described as 1 to 4 thus: 
Tier 4: Specialist surgical 
Bariatric surgery, gastric bands. 
Specialist follow up.
Tier 3: Specialist Weight Management 
Access to multi-disciplinary team e.g. dietetic led 
programme, psychological expertise, 
Tier 2: Primary Care 
NHS Healthy Weight programmes, Lifestyle Adviser, 
Community Dietetic. Drug therapy if appropriate supported by 
local clinical guidance. 
Tier 1: Population-wide health improvement work 
Community interventions including active referral, walking groups, leisure club 
classes, cooking classes. Links to Obesity Route Map. 

To provide agreed referral guidelines for patients from Tier 3 into Tier 4 
services including national gateway criteria. 
Patients referred to Tier 4 services should be seen for their first pre surgery 
assessment (see below) within the referral to treatment pathway i.e. 18 weeks 
from when they leave Tier 3 to first being seen in Tier 4.  Once surgery is 
agreed, the patients must receive treatment within 12 weeks. 
Path ay for 
Referral to Ti
Referral to T er 4 Bariatric Surger
y Se
ƒ  Tier 2: Primary Care management of diabetes and/or obesity 
ƒ  GP identifies patient in priority group(s)* 
ƒ  Type 2 diabetes, Age 18-44, BMI 35-40kg/m2, diabetes <5 yrs  
Referral to Tier 3 / specialist weight management 
Discharged due to 
non-attendance (12 
Patient opts into Tier 3 services 
month lock out from 
ƒ  Successful completion of 
ƒ  Weight gain (5kg) 
specialist weight management 
ƒ Other 
ƒ Patient 
Weight maintenance or loss 
Tier 4 referral 
ƒ Major 
Referral onwards to Tier 4 
Maintenance within 
service for assessment and 
Tier 3 as per local 
*see priority groups below 

Below is the gateway criteria for consideration of access to Tier 4 services. 
Priority group 1 
Individuals who are aged between 18-44 with a BMI 35-40 kg/m2 and recent 
(less than 5 years) onset of Type 2 diabetes 
•  Completion of Tier 3 intervention of at least 6 months duration with local 
programme compliance and completion of required activities e.g. food 
•  Weight maintenance with additional weight loss of 5kg where possible  
•  Glycaemic control – HBA1c maintained at <9% on completion of Tier 3 
and supportive behaviour change compliance including achievement of 
locally agreed behavioural goals  
No contraindication to surgery identified  
Priority group 2 
Subject to all Priority 1 patients being offered treatment and local Board 
agreement, individuals who are aged between 18-44 with a BMI of 40-50 
kg/m2 and onset of Type 2 diabetes  of < 5 years  
•  Completion of Tier 3 intervention of at least 6 months duration with local 
programme compliance and completion of required activities e.g. food 
•  Weight maintenance with additional weight loss of 5kg where possible 
•  Glycaemic control – HBA1c maintained at <9% on completion of Tier 3 
and supportive behaviour change compliance including achievement of 
locally agreed behavioural goals  
•  No contraindication to surgery identified  
Individual reviews  
Assessment of patients who do not fulfil the criteria agreed by NPF through 
the use of local Board review panels for individual cases  
•  Completion of Tier 3 intervention of at least 6 months duration with local 
programme compliance and completion of required activities e.g. food 
•  Weight maintenance with additional weight loss of 5kg where possible 

To determine what the relative clinical effectiveness, cost effectiveness and 
safety of different bariatric surgery techniques (gastric bypass, gastric banding 
and sleeve gastrectomy) among: 
-  Individuals who are aged between 18-44 with a BMI 35-40 kg/m2 and 
recent (less than 5 years) onset of Type 2 diabetes 

Individuals who are aged between 18-44 with a BMI of 40-50 kg/m2 and 
onset of Type 2 diabetes of between 8-10 years 
In the absence of robust evidence the choice of procedure should continue to 
be decided by the individual patient and surgeon as it is for any other surgical 
procedure.  All units providing bariatric surgery should provide a range of 
procedures including banding but also bypass or sleeve and consideration 
should be given regarding any special requirements for women who are of 
child bearing age. 
As at present there should be the relevant clinical safeguards and 
competencies within the unit providing these procedures. 
Key Points Considered 

•  As the patient groups of interest were very tightly defined, there is 
limited direct evidence available to answer the question. 
•  The available data suggests that weight loss is more pronounced with 
gastric bypass and sleeve gastrectomy, and less so with banding. 
While banding appears less effective than other bariatric procedures, it 
is associated with fewer serious adverse side effects. 
•  Evidence from systematic reviews (of mainly lower level studies) 
suggests that bariatric surgery can result in improvements or resolution 
of Type 2 diabetes in many moderately or severely obese people. The 
effects seem to be more pronounced with certain procedures (e.g. 
BPD/duodenal switch, gastric bypass), and in people with newly 
established Type 2 diabetes (<5 years).   
•  A cost-effectiveness study reported that bypass surgery (relative to 
usual diabetes care) had cost-effectiveness ratios of US$7,000/QALY 
and US$12,000/QALY for severely obese people (BMI 35-40 kg/m2) 
with newly diagnosed and established diabetes, respectively. Banding 
surgery had cost-effectiveness ratios of US$11,000/QALY and 
US$13,000/QALY for the respective groups. 

To provide a process for handling exceptional cases which do not fall within 
the new pathway into Tier 4.   
There should be consistency of approach across Scotland and between 
Boards along with the use of a standard format/process for proposed referrals 
into surgery.  
There should however be some flexibility regarding the criteria applied to 
allow for the current differences in service between Boards.  The criteria 
should be transparent and discussed at good practice meetings between 
The recommended process is as follows: 
•  The local Board individual review panel process, either generic or 
bariatric surgery specific should be set up to assess cases; 
•  It should be multidisciplinary and consideration should be given to 
including weight and surgical specialists, psychologists and managers.  
•  There should be a national review of good practice of the Board cases 
carried out on a yearly basis.  This Group should be headed by a 
Medical Director or Director of Public Health. 
The above outlines the best practice advice.  Where the current practice in 
Boards exceeds this approach these should be maintained and examples 
shared at the annual meetings.  

To recommend what data should be collected following bariatric surgery and 
also how this data should be collected.   
It was recommended that the following fields be collected by boards  
Patient CHI 
Criteria for selection for surgery -  
Type 2 DM 
Diabetes Medication 
Insulin   GLP-1 
Details at time of first assessment in Tier 3 service – 
Co-morbidities (non-mandatory) 
Exceptional Criteria /Reason for surgery (free text) 
Operative Procedure description 
Operative OPCS 4 code 
Date of Operation  
Weight at time of operation  
Weight 1 year post op  
Weight 2 years post op  
Diabetes Medication at 1 year  
Diabetes Medication at 2 years  
2nd Operative Procedure Description
Operative OPCS 4 Code 
Date of Operation  
Weight at time of operation  
Weight 1 year post op  
Weight 2 years post op  
Diabetes Medication at 1 year  
Diabetes Medication at 2 years 
3rd Operative procedure Description 
Operative OPCS 4 Code 
Date of Operation  
Weight at time of operation  
Weight 1 year post op  
Weight 2 years post op  
Diabetes Medication at 1 year  
Diabetes Medication at 2 years 
Date of Operation  

Boards should consider the best way in which to collect this information. 
The cost effectiveness of procedures will be reviewed and will determine future needs. 

To provide a follow up protocol which should be used for people following 
Bariatric Surgery.   
Follow-up after bariatric surgery consists of several components. Follow-up 
will be more intensive in the short to medium term, with lifelong follow-up 
required to detect late complications. 
Short to medium term (up to 2 years) 
This will take place within the Tier 4 service. 
•  Surgical: band adjustments, post-operative complications monitoring 
including nutritional bloods 
•  Dietetic: dietary assessments and advice 
•  Psychology: psychological support 
•  Advice on following physical exercise guidance (30 minutes 5 x a week 
where possible) and avoiding sedentary behaviour (in keeping with 
brief interventions)  
The design of services may vary between areas. Efforts should be made to 
ensure efficiency and avoid duplication of effort between members of the 
team. Patient burden should be taken into account when designing services. 
Innovative solutions may be required for rural settings, although all 
practitioners should have the support of being part of a multi-disciplinary Tier 
4 service (e.g. joint training, CPD, MDT meetings). 
Long-term (lifelong from 1 year post-op) 
The purpose of lifelong follow-up is the early detection of complications and 
referral back to Tier 4 services when appropriate. This can occur in primary 
care (Tier 2) from 2 years post-operatively with a shared care system from 1 
year post-operatively.  The shared care can be with Tier 3 or Tier 2 depending 
on local arrangements.  Depending on local arrangements the follow-up may 
remain between Tier 3 and Tier 4.  
This will include: 
•  Advice on following physical exercise guidance (30 minutes 5 x a week 
where possible) and avoiding sedentary behaviour (in keeping with 
brief interventions)  

• Weight 
• Nutritional 
• Complications 
Clear guidance will be required on the monitoring protocol, frequency of blood 
tests and the limits and actions to be taken on blood and weight results. 
Bloods tests and frequency are outlined in SIGN 115.  
As bariatric surgery will affect the care of obesity-related co-morbidities, there 
should be close communication between health professionals for effective 
management of patients’ co-morbidities as weight loss occurs (SIGN 115). 
For example general practitioners, diabetes services and sleep services. 
The Adult Exceptional Aesthetic Referral Protocol should be followed for any 
queries on body contouring surgery.   
CEL 27 (2011) Updated Adult Exceptional Aesthetic Referral Protocol  
The Guidance on Arrangements for NHS patients receiving healthcare 
through private healthcare arrangements
 provides the principles to be 
followed when patients attend following private care 
Peer support groups 
Patient to patient support groups can be very useful and are already available 
in most board area. Internet-based support may be helpful in rural areas. The 
use and growth of these support groups should be encouraged. 

Group Membership 
Member Representing 
Ms Heather Knox Co Chair 
Dr Jennifer Armstrong Co Chair 
Scottish Government Health and Social 
Care Directorates 
Dr Sara Davies 
Scottish Government Health and Social 
Care Directorates 
Mr Ian Ross 
West of Scotland Planning Group 
Dr Carol Craig 
West of Scotland Planning Group 
Ms Jan McClean 
South East & Tayside Planning Group 
Stuart Oglesby 
South East & Tayside Planning Group 
Ms Roseanne Urquhart 
North of Scotland Planning Group 
Mr Duff Bruce 
North of Scotland Planning Group 
Dr I Bashford 
Medical Director 
Dr Susan Myles 
Healthcare Improvement Scotland 
Mr Andrew de Beaux 
Scottish Academy 
Susan McFadyen 
Greater Glasgow and Clyde 
Dr Jennifer Logue 
Dr Shareen Forbes