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Bariatric surgery within tariff

The NHS budget for England in 2010/2011 is £102.3bn, part of which (approximately £80bn) buys 2.7 acute care hospital beds per 1,000 of population. However, the NHS has been directed to secure efficiency savings of between £15bn and £20bn over the next four years. Bariatric surgery therefore, despite the well documented evidence of its cost effectiveness, has come under increasing financial scrutiny from those who commission services. This is on a background of increasing demand for and utilisation of the surgical management for obesity. Analysis of Hospital Episode Statistics (HES) data for 2009/10 indicates that over 6500 NHS-commissioned metabolic surgery procedures were performed in England. However, this accounts for just 1% of those who were eligible for surgery, so the financial outlay required to service the demand presents a huge challenge to the cost squeezed Primary Care Trusts (PCTs).

One of the tools that the PCTs have used to control their financial exposure is local adjustment of the NICE guidelines for eligibility for surgery, thereby leading to the so called “postcode lottery”. Another is by squeezing the hospital’s remuneration for activity. Providing a bariatric service therefore, may actually prove to be a financial risk for providers. The PCTs fund surgery for patients who are properly coded and grouped to the relevant Healthcare Resource Groups (HRG). These seem to be FZ04 and FZ05 in the main, with gastric bypass usually coding to FZ04a and gastric bands to FZ05a. The band tariff includes the cost of the band itself. These tariffs are set out in the table below. There is also a small Market Forces Factor (MFF) which is paid on top of this. Providers also need to be aware that hospital readmissions within 30 days of surgery will not be funded either.

HRG Code FZ04A FZ04B FZ05A FZ05B
HRG Name Very major stomach or duodenum procedures with major comorbidities Very major stomach or duodenum procedures without major comorbidities Major stomach or duodenum procedures 2 years and over with comorbidities Major stomach or duodenum procedures 2 years and over without comorbidities
Tariff (£) 8713 5268 3620 2460

The challenge is set out therefore, for providers to deliver safe and cost effective care. Care pathways that are designed to increase efficiency without compromising on quality will be demanded from those managing the organisations that provide the care. The message is the same across the NHS of course, but in order to be able to properly service the demand for bariatric services, the providers will need to be reassured that their sums add up.