The process of applying for NHS funding for your weight loss surgery
Where do I start?
You have had some information about weight loss surgery and feel you would like to pursue this for yourself but are unsure where to start. There are some fundamental stages which, if followed, should avoid some of the common pitfalls:
1. Make sure you understand the most common weight loss surgical procedures. You can do this by researching the forums and looking under the surgery specific forums. Many people find that joining the surgery specific chat nights gives them the opportunity to ask questions of the people who live with that option every day. There is information about all the current surgical options which can be accessed via the home page. It is also extremely helpful at this juncture to identify where your nearest wlsinfo affiliated support group is and make contact with the support group coordinator with a view to attending the group so that you can have face to face discussions with other local people who have been in your situation.
2. There are eligibility guidelines for weight loss surgery (also referred to as obesity surgery or bariatric surgery) produced by the National Institute for Clinical Excellence (NICE) These can be found on their website www.nice.org.uk. It would be helpful for you to read these prior to seeing your GP so that you know whether you fulfill the criteria.
3. In summary NICE advises that a person should be considered for surgery if:
a)They have a BMI of over 40 and have tried to lose weight by attending a weight management programme and have also tried, where appropriate, the available prescription anti-obesity drugs and been monitored by their family doctor.
b) They have a BMI of over 50. In this case weight loss surgery can be considered without the patient having necessarily tried different approaches to lose their excess weight.
c) If the person has a BMI of 35-40 but has one of the serious co-morbidities e.g. Type 2 diabetes, hypertension, sleep apnoea, and other weight loss options have failed.
Contacting the PCT
4. Once you have identified where you fit into these criteria it is helpful to ring your local Primary Care Trust and speak to the person who deals with funding requests and ask for a copy of the local protocols for funding. You can ask for them to be emailed to you and a hard copy sent to your postal address. It would also be helpful to you to establish the details of the surgical team who provide weight loss surgery in your locality. You should encounter no problems gathering this information. If you are anxious about doing so you could ask someone to do so on your behalf.
5. This may appear to be a long process but it should save time and anguish is the long run.
Discussion with your GP
6. It invariably helps to make a list of the ways in which your weight negatively impacts on your life because it is hard to remember every point you wish to make in a short consultation. Some people find it helpful to ask members of the wlsinfo forums what they feel are the main issues to include. If you are able to identify these and take a copy to your GP appointment for your medical file it gives him/her vital information to aid the application (please see sample document).
7. Make an appointment to see your GP to discuss your decision to apply for funding for weight loss surgery. At this time your GP will note the seriousness with which you are approaching this decision as you will be able to identify in which ways you fit the NICE criteria, the surgical option you favour and the fact that you have made contact with the local support group and this charity.
8. You may have a GP who is well versed in applying to the PCT for funding for this kind of surgery. If not I'm sure it would be helpful to bring a copy of the locally agreed protocols for their information.
9. There are some PCTs who do not require individuals to apply for funding as they have agreed to fund patients who fulfill the locally negotiated criteria. Please note this is very likely to differ from the NICE guidelines in entirety. An example of this is a PCT who has in place an agreement to fund any patient with a BMI of over 50 if the bariatric surgeon believes this to be the best course of action.
10. On the whole it is necessary for your GP to make the case for you requiring NHS funding for this surgery. It is always advisable to ask to have sight of this before it is sent in order to ensure there are no inaccuracies. It also helps if you have a copy of all correspondence exchanged in this matter and it is your right to do so.
11. If you find your GP unsympathetic to your request you could arrange to consult with another GP in your practice or if necessary consider changing to another practice but not before establishing with the new Practice Manager that there are doctors experienced in making successful referrals for funding for weight loss surgery.
Tracking the request for PCT funding
12. It is best to accept that your GP is a very busy professional and that the need to write this application will be competing with other expectations on her/him. It is therefore important for you to track the process. You can do this by ringing your GP's secretary after a week and ask if the request has been written and sent out. If it has you should ring the PCT to check they are in receipt of it and if not arrange for it to be faxed the same day. It would be good to use this opportunity to check when the Panel will be meeting to consider this request and how and when you will be notified.
13. If you have not been asked to submit a report enumerating the reasons for you wanting to have weight loss surgery you may decide to do one anyway. Not everyone is confident in writing such a report so it is helpful to use all the collective experience of the charity to see what others have written or ask for suggestions. Invariably someone will be able to send you a copy of a letter that they sent with a successful outcome. There will be a deadline for any submissions to be considered by a panel so check that date and ensure that everything you wish to be taken into account is submitted in plenty of time.
14. If you wish to be informed directly about the Panel's decision this needs to be documented on your PCT file. You may wish to ring the contact person at the PCT the day after the Panel has convened and ask for the outcome. It is unlikely you will be given this by phone but ask when the letter will be sent out to you and your GP.
15. Once you receive your letter with the outcome it can go two ways. If you have been successful in securing funding your GP will refer you to the local bariatric team for assessment. If you have been refused funding you will need to lodge an appeal. In order to do so you will need to know the grounds under which you were denied funding and it is vital that you have a written copy of the appeals policy and adhere to the timescales.
16. It is natural to feel discouraged at this stage but many members have had positive outcomes from an appeal. If you have a sympathetic GP you will need to liaise with her/him. If you consider that the process has not been followed to the detriment of your outcome you may choose to involve additional support at this stage.
17. Your appeal could be based on the following:
The panel did not have all the information they needed to make an informed decision.
The panel did not follow their own procedures
The criteria does not equate to the NICE criteria and is thus inequitable
Access to weight loss surgery is subject to a postcode lottery
18. It is critical that from the beginning of this whole process you keep a detailed file on your request for weight loss surgery and that you keep copies of all correspondence, including emails in this. It is helpful to document any phone calls you have noting the person's name and position and details of the conversation. This is helpful when you involve someone else in your case.
19. At this point you may wish to involve PALS, your local MP, the Minister for Health and the Chief Executive of the PCT. A rule of thumb is to be polite at all times in both phone and written contact with anyone from the PCT. It does not help your case to be rude.
To continue the fight or not
20. You need to reconsider how closely you meet the NICE guidelines. If you are outside of these your case will be very hard indeed to win and you may at that stage want to consider alternatives. If you firmly meet all of the NICE guidelines it is important for you to appeal.
21. Not everyone is confident about representing themselves at an appeal level although it is unlikely that you would be asked to attend in person. You could ask PALS or your MP to do so on your behalf.
22. If you believe that the decision making process about your case has been deeply flawed you could consult a solicitor about the possibility of asking for a Judicial Review. This is where a judge is appointed to look at the case and make judgment about whether the PCT's decision stands up to scrutiny. This is a last resort but if you are determined to see justice win the day you may decide to pursue it.
23. Many appeals have a successful outcome but sadly some don't. It is experienced as a personal blow to someone who knows that weight loss surgery is the only way to regain good health. Each case is individual but it may be that the PCT is asking for you to follow another treatment plan before you can apply again. There are many persistent people who are members of this site who fought for years before securing NHS funding so it's important to keep your hopes alive.