In Shape for Surgery

Ensuring patients are In Shape for Surgery – what this means in practice

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 August 2017 primary care is requested to follow this "best practice" recommended Clinical Referral Guideline (CRG).

When referring patients who are likely to have hip arthroplasy, 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 – consider referral for ECHO in newly detected heart murmur

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.


From August 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 or any other elective surgery

Patients who are being referred for a surgcial 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

Referral criteria (within 3 months of the referral)

Criteria Threshold for pre-referral intervention
Medical Markers - chronic disease management
Medical Markers - chronic disease management
(for hip and knee arthroplasty only unless high anaesthetic risk)
Hb less than 120g/L in females and 130g/L in males
(excluding anaemia related to chronic disease)
Blood pressure BP greater than 160/100mmHg
- In known diabetics and
- In those at risk of diabetes as identified by a BMI ≥ 30.
Diabetes UK risk tool is also recommended ( here)
HbA1c greater than 69mmol/mol
Irregular Heart Beat (ECG if pulse rate greater than 100 or irregular)
Atrial Fibrillation with a rate greater than 100 beats per minute
Auscultate for heart murmur
Un-investigated heart murmur
Lifestyle Criteria Lifestyle Criteria
(Vaping and Nicotine Replacement Therapies are not restricted)
Smoker. Advise patient:
- 8 weeks smoking cessation prior to operation is optimal to reduce risks;
- it is a good time to consider quitting for good;
- and sign-post to smoking cessation service.

It is acknowledged that these thresholds are not achievable, or even desirable, for a small number of patients due to their co-morbidities. If your patient doesn't meet these thresholds, but you feel they are as well optimised as possible ("best optimised") for surgery, with their risks from surgery minimised as much as reasonably possible, then this should be stated in the referral letter.

Smoking cessation should be initiated in primary care, with patients being signposted to existing smoking cessation services for advice on nicotine replacement therapy and other methods of smoking cessation. This signposting should occur at the time of referral to secondary care. Carbon monoxide testing will take place during hospital appointments to support their quit attempt.

When patients who smoke are seen in secondary care and it is decided it is appropriate to operate for their condition the importance of being smoke free for surgery will be re-iterated to them. If they are unsuccessful in their quit attempt during that period they can still proceed to surgery.

There is already rigour and professional guidance in pre-operative assessment of people with alcohol and substance misuse issues. No substantial change of practice is envisaged at this time beyond an added emphasis on screening patients judged or known to be at risk by their GP.

Patients with very high or very low body mass index (BMI greater than 40 or less than 18) are at additional risk in surgery and this risk should be raised with them.

Patients who require health optimisation can be referred to the appropriate healthy lifestyles service using the resources available locally:

Referral form

DRSS referral template - no merge fields

Guide to accessing GP clinical system specific referral templates

Please note there is an existing hernia policy and this policy includes advise on smoking cessation prior to incisional hernia repair.


N.B. if you have so far been unable to optimise your patient with regard to any of the above criteria, please include details of current/previous interventions in your referral. .

Supporting Information

Further information & resources

In Shape for Surgery - practice pack

In Shape for Surgery - stakeholder briefing

In Shape for Surgery - evidence summary

In Shape for Surgery - questions and answers

In Shape for Surgery - update for GPs

Patient information

In Shape for Surgery - Patient website

Patient Leaflets
Patient feedback contact details

NEW Devon CCG patients


  • British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Alwyn Kotze et al British Journal of Haematology 2015; 171: 322–331
  • Type 2 diabetes: prevention in people at high risk. NICE Public health guideline (PH38). July 2012
  • Peri-operative management of the surgical patient with diabetes. Association of Anaesthetists of Great Britain and Ireland Anaesthesia 2015; 70: 1427–1440
  • Management of adults with diabetes undergoing surgery and elective procedures: improving standards. Joint British Diabetes Societies for Inpatient care (JBDS-IP). Revised September 2015.
  • The measurement of adult blood pressure and management of hypertension before elective surgery. Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society. Anaesthesia 2016; 71(3): 326–337
  • Major complications of airway management in the United Kingdom, Chapter 20: Obesity. NAP 4: 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Report and findings March 2011
  • Body mass index and risk of perioperative cardiovascular adverse events and mortality in 34,744 Danish patients undergoing hip or knee replacement. Thornqvist C. et al Acta Orthopaedica 2014; 85 (5): 456-462
  • Perioperative Outcomes among Patients with the Modified Metabolic Syndrome Who Are Undergoing Non-Cardiac Surgery. Glance L.G. et al Anesthesiology 2010; 113(4): 859-872

Pathway Group

This guideline has been signed off by the Planned Care Control Centre on behalf of NHS Devon CCG.

Publication date: August 2017


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