NHS bodies must stop breaking guidelines and ‘rationing’ surgery, says charity
26 March 2026
Arthritis UK
NHS bodies must stop breaking guidelines and ‘rationing’ surgery, says charity
Arthritis UK is calling on NHS Integrated Care Boards in England to stop flouting guidelines by rationing surgery based on a person’s BMI (body mass index).
In its new report published today, it has found almost one fifth (19%) of ICBs across England that have policies in place that refuse or delay joint replacement surgery based solely on an individual’s weight, creating a postcode lottery of care. A further 54% have BMI policies in place that alter or restrict access to surgery. This practice breaches National Institute for Care and Excellence (NICE) Guidelines, Government policy* and has been criticised by the Royal College of Surgeons and the British Orthopaedic Association.
Deborah Alsina, Chief Executive of Arthritis UK, said:
“This practice is unfair and flies in the face of all guidelines and evidence. People waiting for joint replacement surgery, often due to arthritis, have already spent many months or years with their health and mobility in decline as joint replacement surgery is the final line of treatment. Joints in need of replacement are incredibly painful and severely impact the ability of individuals to exercise which can lead to weight gain. It is counterproductive to deny surgery that could get people back on the road to mobility and improved health and fitness.”
The charity’s call comes at a pivotal moment in the reshaping of the NHS, as ICBs – which are responsible for commissioning and co-ordinating local NHS provision – will begin to merge from April. The merger will necessitate newly clustered ICBs to review which policies to adopt, and which to abandon.
Ms Alsina said the merger is a chance to throw out the bad and adopt the good:
“The Government has vowed to take the best of the NHS to the rest of the NHS, and this is a good place to start by abolishing bad practice that penalises individuals’ access to vital surgery because of where they live.”
The following ICBs have policies with BMI thresholds to ration the use of surgery: Black Country, Coventry and Warwickshire, Herefordshire and Worcestershire, Leicester, Leicestershire and Rutland, Lincolnshire, Shropshire, Telford and Wrekin, Staffordshire and Stoke-on-Trent and Sussex. The thresholds however are not consistent. Lincolnshire ICB, for instance, will not offer surgery to a patient with a BMI above 35, whereas Leicester, Leicestershire and Rutland ICB will not offer surgery to patients with a BMI above 45 (a difference of about 13kg) (see full list in Notes to Editors)
The use of restrictive BMI policies was brought to light last year by University of Bristol academic Dr Joanna McLaughlin who discovered ICBs were refusing surgery on the grounds of individuals’ weight**. The charity has deepened and widened the investigation to uncover the extent to which BMI is being used to ration surgery across all ICBs**. This has revealed there is a hotchpotch of approaches with some areas demanding patients lose weight, but with no clear target or support to do so, and no provision or solution if patients fail to lose weight.
The Royal College of Surgeons of England and the British Orthopaedic Association, the professional association in Britain for doctors who specialise in orthopaedic surgery, have both backed the charity’s report.
Fergal Monsell, surgeon and President of the British Orthopaedic Association, said:
“Improving someone’s health before planned surgery is usually helpful. However, losing weight (reducing BMI) is not always easy and may not significantly lower the risks of surgery. Refusing or delaying surgery until a patient loses weight could be seen as unfair.
“In fact, waiting to have surgery while trying to lose weight may make patients less fit, increase their pain and disability, and reduce their overall physical condition. Denying someone the benefits of planned orthopaedic surgery based only on BMI is not evidence-based, and differences in rules across the UK mean access to treatment can depend on where someone lives, resulting in a ‘postcode lottery’.”
Mr Tim Mitchell, President of the Royal College of Surgeons of England (RCS England), said:
“Supporting patients to reach a healthier weight before surgery can reduce complications, but BMI alone should not be a barrier to surgery. Surgical decisions must be made case-by-case, reflecting each patient’s individual circumstances.
“Timely surgery can significantly improve a patient’s quality of life. Delays can lead to loss of mobility and further health problems. We must not penalise those who are less fit but still eligible for an operation. ICB policies that do this are unfair and ignore clinical guidance.”
ICBs seek to justify the use of BMI policies by citing the increased surgical risk associated with a higher BMI score. Where research evidences only a significant risk in those with a very high BMI for example over 45, it has been inappropriately used to justify policies that enforce a cut off at lower BMIs of for example 35 plus, affecting many thousands of adults who would have received the significant improvements in their joint pain and function. Multiple large-scale studies demonstrate the benefits of surgery outweigh the risks, making surgery cost effective for the vast majority of patients.
Arthritis UK is concerned that ICBs are implementing BMI policies in a bid to cut waiting lists, and costs. Ms Alsina adds:
“The Department for Health and Social Care should ensure that any efforts to reduce waiting lists are not achieved through policies that contravene clinical evidence or to the detriment of a patient’s wellbeing.”
The Trauma and Orthopaedic (T&O) waiting list, which includes joint replacement surgery, has consistently been the largest single cohort of those waiting for treatment and has the highest number of cases. National referral to treatment (RTT) targets have not been met since 2015. The elective reform targets in England of 65% of patients treated within 18-weeks and waits longer than 52 weeks reduced below 1% of the total waiting list by March 2026, were missed last week.
The report found the human cost of delays to treatment can result in prolonged pain and further deterioration of the joint, which can reduce mobility and result in irreversible damage that earlier surgery could have prevented. Waits of over six months for hip and knee replacement surgery have been shown to have a detrimental impact on health-related quality of life and frailty, with two-thirds of patients feeling their health had worsened.
Specifically, BMI threshold policies, which delay surgery, have been associated with worsening symptoms (based on a pre-operative Oxford Hip Score) and increasing obesity in the surgical patient population, as a result. This illustrates that BMI policies not only have a detrimental effect on symptoms, but they are also counter-productive in supporting people to lose weight.
Arthritis UK is currently contacting all ICBs named in the report with its findings and hopes to see the cessation of BMI policies to restrict access to surgery. The charity is also calling for the Government’s support in reaffirming its expectations of all ICBs to provide equity in care, and adherence to Government and NICE guidelines.
To read the report in full visit Beyond BMI: Removing Harmful Barriers to Joint Replacement Surgery
Ends
Notes to editors
For more information, please contact the Arthritis UK Press Office by emailing press@arthritis-uk.org or calling 0300 7900456.
Table of ICBs and their policies attached.
* Health Minister Karyn Smith responded to a Prime Minister's Question tabled by the charity in November 2025. She said: “As with all surgery, BMI would be considered as part of a holistic, personalised perioperative evaluation of the risks versus clinical need for joint replacement surgery of an individual patient. However, BMI should not be considered in isolation and in and of itself should not act as a barrier to surgery.” Full response found here: Written questions and answers - Written questions, answers and statements - UK Parliament
**Dr Joanna McLaughlin’s research was funded by the National Institute for Health and Care Research (NIHR) – JM held an NIHR Doctoral Research Fellowship (NIHR 301469) and was supervised at Bristol Medical School, University of Bristol, UK. The views expressed in this research are those of the authors and not necessarily those of the NHS, the National Institute for Health and Care Research or the Department of Health and Social Care.
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