Prior Approval Referral Cover Sheet to Orthopaedics for

Hip or Knee Osteoarthritis (Adults – 18 and over)

All applications are assessed against policy No.’s 32 & 33

All policies can be viewed at https://prioritiesforum.org.uk/
All clinical pathways can be viewed at https://clinical-pathways.org.uk/
Date

GP details Name Direct Dial Tel No:

(For queries)
Practice Address::

Patient details Name: Date of birth: - - / - - / - - - -

Address:

Telephone number: NHS No:

Patient consent This application has been discussed with the patient and the patient consents to relevant
information being shared with the Clinical Commissioning Group.

Please specify HIP / KNEE LEFT / RIGHT / BILATERAL

Smoking status Current smoker Ex-smoker Never smoked

Last quit attempt Date: - - / - - / - - - -

For patients who smoke or quit smoking less than 8 weeks ago:
Patient has been referred into Hertfordshire Stop Smoking Service ((HHIS) Stop
Smoking Service

Patient has refused a HHIS referral

Patient is aware they will need to have stopped smoking or switched to e-cigarettes
for at least 8 weeks prior to surgery. If they successfully quit smoking, HHIS will provide
them with a certificate that they need to take to their pre-operative assessment

Measurements Height: ………. cm Weight: ……….. kg BMI …..…… kg/m²

You may still refer your patient for an orthopaedic opinion however;

Patients with a BMI >40 are expected to lose weight and will not receive surgery until
they reduce their weight by 15% over 9 months or reduce weight to BMI <40 (whichever is
greater)

Patients with a BMI 30-40 will need to lose 10% of their weight over 9 months or reduce
weight to BMI <30.

The policy and a target weight calculator tool can be found at

https://prioritiesforum.org.uk/fitnessforsurgery

Please state the patients target weight for surgery ….………… kg

Please advise your patients of this when referring and provide them with a leaflet and
weight management support as appropriate.

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 Also note:

1. If weight loss has already been initiated or achieved prior to referral, please provide
details of previous recorded measurements and date recorded by clinician:

Previous Weight: …………..kg Previous BMI ………… kg/m²

Date measured ……………. % weight reduction = ……….

Exclusions 2. Exclusions to BMI restriction for hip and knee surgery:

• patients whose pain is so severe and/or mobility so compromised that they are in
immediate danger of losing their independence and that joint replacement would
relieve this threat;
• patients in whom the destruction of their joint is of such severity that delaying
surgical correction would increase the technical difficulty of the procedure.
• patients whose BMI is artificially affected by large muscle bulk e.g.
Sportsmen/women
• If you suspect your patient meets these criteria, please include your
evidence and rationale for this. These exclusions must be supported with
clear evidence.

Non-surgical Treatment Yes / No Dates/Type/Dose/Duration/Comments

treatment
Analgesia

Details must NSAIDS

be provided.
Changing activity

Walking aids

Physiotherapy

Weight reduction if BMI >25

Joint injections

Other (please specify)

Oxford Score Please complete Oxford Hip or Oxford Knee Score. Score:

For patients with a score of 0-19 consideration should be given for orthopaedic surgical
opinion.
For patients with a score of 20-29 conservative measures should be continued for 3-6
months. Patients should be referred if no improvement.

Radiographic
changes X-ray evidence None Mild Moderate Severe
of joint damage?

Exceptional If your patient does not meet the above criteria but, in your opinion, there are grounds of
cases exceptionality to the policy, please provide details of this in an accompanying letter.

Email the completed form, GP referral letter and X-ray report to

priorapproval.hertfordshire@nhs.net
Clinical Funding team 01707 685354

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