People living with obesity denied joint replacement surgery contrary to national guidelines

People with a high body mass index (BMI) are being denied joint replacement surgery, despite guidelines from the National Institute for Health and Care Excellence (NICE) saying decisions on whether to offer surgery should not be based only on a person’s BMI. These are the findings from a study involving Bristol BRC researchers, published in the Journal of Health Services Research & Policy.

The study found one third of Integrated Care Boards (ICBs) in England – the organisations responsible for setting local healthcare policies – have policies which may prevent people with high BMI being eligible for joint replacement surgery. Many of the other ICBs have ambiguous policies.

These policies contradict NICE guidelines, which explicitly advise against deciding whether to refer patients for surgery solely based on their BMI. The guidelines suggest decisions about treatment should instead be based on a person’s clinical need.

Restricting access to joint replacement for people with high BMI can worsen health inequalities. The highest percentage of obesity is in black adults, and obesity rates are higher in more deprived areas. Preventing people with a high BMI receiving replacement joints is likely to disproportionately affect these groups.

The study looked at the policies on who is eligible for hip and knee replacement surgery at all 42 ICBs across England, in February 2025. The findings suggest ICBs’ policies are changing, but the extent to which they have adopted the latest NICE guidelines varies hugely across the UK.

More research is needed to find out how BMI-related eligibility criteria are enforced in practice and how this affects patients’ access to care.

Dr Katie Whale, Health Psychologist and study co-author said:

“This work shows access to joint replacement surgery still depends heavily on where you live. In many areas, having a high BMI means you are denied or delayed surgery, leaving people waiting longer while their health worsens.

“These restrictions are also more likely to impact socio-economically disadvantaged groups, increasing inequity in care.”