Beyond BMI: Removing Harmful Barriers to Joint Replacement Surgery

Over 7 million people in England have osteoarthritis (OA) of the hip or knee. Joint replacement surgery is regarded as a clinically and cost-effective treatment for managing advanced OA, and most patients experience a good outcome from surgery.

However, we now have evidence that almost a fifth (19%) of Integrated Care Boards (ICBs) in England are rationing joint replacement surgery by disadvantaging patients with a higher Body Mass Index (BMI). A further 54.7% have policies that restrict or alter access to surgery in some other way for those with overweight or obesity.

Not only are these policies unfair, but they also contradict National Institute for Care and Excellence (NICE) Guidelines and Government policy.

'Beyond BMI: Removing Harmful Barriers to Joint Replacement Surgery' sets out the evidence and impact of Integrated Care Boards (ICBs) in England using body mass index (BMI) thresholds as a way of rationing joint replacement surgery.

While we recognise the pressures that ICBs face to cut costs, these policies are unfair. They can lead to delays in surgery, leaving people with arthritis in pain for longer. This significantly affects their quality of life. Arthritis UK is calling for all ICBs to stop using these policies and stop rationing surgery based on a person’s BMI alone. 

Arthritis UK makes the following recommendations: 

• BMI threshold policies should not be used to ration access to joint replacement surgery, instead decisions should be based on individual clinical need and ICBs policies should be updated accordingly.   
• ICBs should ensure that surgical access policies are clearly worded, removing ambiguity for patients and clinicians about health optimisation expectations. 
•  ICBs should adhere to NICE osteoarthritis guidelines.
•  ICBs should ensure adherence to NHSE early screening, triaging, risk assessment and health optimisation in perioperative pathways guidance.
• The Department of Health and Social Care should ensure that any efforts to reduce waiting lists do not rely on policies that contravene clinical evidence or undermine patient’s wellbeing.  
• The Secretary of State for Health should ensure new ICBs are not using blanket BMI policies to remove people from waiting lists for orthopaedic surgery. The government's ambition to reduce waiting times before the end of this parliament should not come at the expense of people with obesity/high BMI. 
• ICBs and local authorities should ensure, through long-term ringfenced funding, that appropriate weight management services and interventions for people with arthritis and MSK conditions are commissioned, available, accessible and integrated. 
• Healthcare professionals should offer weight management support from the onset of joint symptoms and continue after surgical intervention; weight management support should not be offered solely for the purpose of surgery.