When a patient has poorly controlled chronic disease or other risk factors, it can adversely affect the:

• outcome of the operation
• risks of complications during and after surgery
• length of time spent in hospital
• patient's recovery time
• NHS costs, resources and health professional time needed to care for the patient in hospital and following discharge

The message to patients is simple, and can be re-iterated at every opportunity in both primary and secondary care "surgery puts stress on the body, so the healthier you are, the better you'll handle it."

From December 2017 primary care is requested to follow this best practice recommended Clinical Referral Guideline (CRG):

When referring patients who are likely to have hip arthroplasty, knee arthroplasty or hernia surgery, primary care is requested to measure the information below and, where possible, optimise any medical conditions prior to referral.

• HbA1c (in known diabetics, those with pre-diabetes and those with a BMI greater than 30)
• Haemoglobin
• Blood pressure
• Pulse check for atrial fibrillation
• Auscultation of heart for new heart murmur

With regard to these measurements, prior to referral for surgery primary care is asked to investigate and optimise the conditions in the following circumstances:

• HbA1c greater than 69
• Haemoglobin less than 120g/l for females and 130g/l for males
• Blood pressure greater than 160/100
• Atrial fibrillation rate greater than 100
• Heart murmur – ECHO should be obtained if concurrent symptoms and/or ECG abnormalities

Smokers who are willing to engage in attempting to quit should be signposted to stop smoking cessation services before, or at the time of surgical referral and should be advised that ideally they should be smoke free for 8 weeks prior to surgery in order to improve their outcomes.

This CRG covers patients who are being referred for "surgery likely."

It is recognised that it is not always clinically desirable or possible to optimise patients to the thresholds set out in this pathway. Should this be the case then referrers are requested to state this in the referral letter in order to assist any decision making in secondary care.

Much of the work in this pathway already happens in practice prior to referral, but is now being formalised through this CRG. Without early intervention these issues frequently result in patients having their procedures deferred, cancelled or being put at avoidable risk.

There is no ban on surgery for people in the categories listed within the referral criteria and there is no blanket policy.

Scope

From December 2017, it is recommended that any adult referral for routine hip arthroplasty, knee arthroplasty or hernia repair should follow this recommended "In Shape for Surgery" guidance.

Out of scope

Patients referred for emergency surgery or clinically urgent surgery

Patients who are being referred for a surgical opinion when the treatment is unclear

Any surgical interventions that may be required as a result of pregnancy

Vulnerable patients where the likelihood of achieving optimisation and benefits from it are low will require individualised consideration. This includes patients with learning disabilities, significant cognitive impairment or severe mental illness

Referrals of a diagnostic nature

Children under the age of 18