Persistent use of body mass index policies as a barrier to surgery: Prevalence and analysis of policies across England in 2025

Background:
Integrated Care Boards (ICBs) in England are responsible for commissioning healthcare services and setting access policies for procedures such as hip and knee replacement surgery. While the National Institute for Health and Care Excellence (NICE) advises against body mass index (BMI)-based restrictions, many ICBs impose such criteria. This study examines the prevalence and content of these policies to understand their impact on equitable healthcare access.

Methods:
A qualitative content analysis was conducted to systematically evaluate the policies set by all 42 ICBs in England regarding access to hip and knee replacement surgery for patients living with obesity. Policies were collected from official ICB websites and Google searches, completed in February 2025, and categorised as: no policy, restrictive policy, and non-restrictive policy. The alignment of these policies with clinical guidance was assessed, focusing on their potential impact on equitable healthcare access.

Results:
Policy documents were identified for 41 ICBs: 26 included weight management guidance and 15 imposed BMI-based restrictions on joint replacement referral eligibility. Policies varied in naming, terminology, and specificity, risking inconsistencies in interpretation and implementation. Some ICBs (n = 3) had revoked BMI-based restrictions in recent policy updates, reflecting a shift towards individualised clinical assessments. These findings highlight variability in policy approaches and the evolving stance on BMI-related eligibility criteria.

Conclusions:
One third of ICBs still use policies that contradict NICE guidance by restricting access to joint replacement surgery for those with high BMI, while many others apply ambiguous language. These inconsistencies highlight concerns about policies that may influence equitable access to care. Further work is required to evaluate how BMI-related eligibility criteria are applied in practice and their impact on health inequalities.