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Access to surgery

Access to bariatric surgery unfair and unethical

NHS decision-makers accused of denying or delaying patients’ access to surgery

At a recent conference hosted by the Royal College of Surgeons (RCS) in the UK, senior bariatric surgeons have blasted access to National Health Service (NHS) weight-loss surgery as ‘inconsistent, unethical and completely dependent on geographical location’. The criticisms were voiced following the publication of an anonymous survey of UK bariatric surgeons.

The survey revealed that restrictions on NHS budgets has resulted in some NHS decision-makers opting to ignore professional guidelines on obesity surgery, and as a result denying patients’ access to surgery. In addition, some patients who already meet the criteria are forced to wait until either they become more obese or develop life-threatening conditions (eg. diabetes or stroke). 

According to the NHS Constitution (published in 2009) morbidly obese patients (those with a Body Mass Index [BMI] 40>) have a legal right to be properly assessed for weight loss surgery under guidelines set out by the National Institute of Clinical Excellence (NICE).

However, the RCS has learned that while some Primary Care Trusts (PCTs) adhere to the guidelines, others are raising the bar so that only the most extremely ill patients (those with a BMI of 50 or 60 with obesity related illness) are being referred for surgery. Surgeons say there is no clinical evidence to support the practice, and not only do these patients have less to gain from surgery but are far more likely to suffer serious complications.

Alberic Fiennes

Mr Alberic Fiennes, President of the British Obesity and Metabolic Surgical Society (BOMSS), said: “We recognise the difficulties faced in dealing with a ‘new’ disease of epidemic proportions but to limit surgery to the most severely obese is unfair and short-sighted and against basic professional ethics. It is also contrary to strategies that are standard for diseases that overwhelm resources.”

Approximately, one million people meet National Institute of Clinical Excellence (NICE) criteria with around 240,000 wanting surgery yet only 4,300 NHS weight-loss operations were carried out last year. Consequently the delay in treating these patients is draining NHS resources, with obesity associated healthcare costs estimated at £7.2billion per annum. Surgeons say there is incontestable evidence that surgery is both cost-effective (with surgery costs recouped within three years as obesity associated costs are eliminated) and the only proven successful method of treating the morbidly obese.

“NICE guidelines are meant to signal the end of postcode lotteries, yet local commissioning groups are choosing not to deliver on obesity surgery,” said RCS Director of Education, Professor Mike Larvin. “In many regions the threshold criteria are being raised to save money in the short term meaning patients are being denied life-saving and cost effective treatments and effectively encouraged to eat more in order to gain a more risky operation further down the line.”

The anonymous survey of UK bariatric surgeons revealed that:

  • Approximately two thirds of surgeons said patients who are eligible under NICE guidelines are refused surgery in their centres. 

  • Criteria for surgery varies dramatically depending on geographical location and within the same Strategic Health Authorities. 

  • Some centres are treating patients with referrals from multiple PCTs with different eligibility criteria meaning that patients with a BMI of 60> are being refused surgery in the same hospitals that are treating patients with a BMI<40. 

  • Some Primary Care Trusts are refusing to commission any obesity surgery.

Surgeons want to see consistency and transparency across the NHS so that patients are clear about what they are entitled to and doctors can treat all patients equally. Furthermore, they are calling for the Department of Health to invest in a longterm strategy to ensure that all patients have equal access to treatment delivered by experienced multi-disciplinary teams working out of properly equipped centres that can offer a full specialist assessment, an appropriate treatment and provide safe long-term follow up and emergency re-admission.

“There is absolutely no doubt that some patients more needy of surgical treatment than others are being denied it,” said Mr Peter Sedman, a Council member of the Association of Laparoscopic Surgeons. “I will treat the patient, my hospital will offer the service, but unless the patient moves house they will not be referred and if they are the treatment is subsequently blocked.”

PCT Response

David Stout, director of the NHS Confederation's PCT Network, said that all PCTs were working with local NHS services to deal with the increasing rates of obesity in England and have arrangements in place to treat those patients who will require surgery. “NICE provides PCTs with guidance on which patients should be considered for weight-loss surgery as part of a wider strategy to address obesity including encouraging natural weight loss through other means. Additionally, all PCTs have public health strategies in place which encourage a healthier diet and lifestyle. PCTs need to balance their priorities across a wide range of services, taking into account NICE guidance in the context local needs. But it is important that all commissioners are transparent in their decision-making.” 

NICE response 

NICE spokesperson commented: “The NHS is currently spending billions of pounds treating obesity and the conditions it causes. If, by recommending surgery for people who are morbidly obese [that is, with a BMI >40kg/m2, or between 35kg/m2 and 40kg/m2 if they also have other serious health conditions], NICE can help to reduce the number of morbidly obese people, we can also make cost savings for the NHS in the long run. 

“There is absolutely no doubt that some patients more needy of surgical treatment than others are being denied it” Peter Sedman

“The NICE guidelines on the prevention, identification, assessment and management of overweight and obesity in adults and children is very clear that this treatment is only for people who are severely overweight, who are already receiving treatment in a specialist clinic and who have tried other treatments to lose weight in the past. 

“It is in the interests of people who are morbidly obese that Trusts work towards offering weight loss surgery according to the recommendations in the NICE guidelines as quickly as possible so that there is consistent and fair access to this treatment in England and Wales. 

“We would strongly urge the NHS to use the criteria set by the NICE guideline so that they can be confident they are working to evidence based standards. We are working to support local NHS bodies to put our guideline into practice and our local implementation consultants are available to offer support and advice to PCTs and Trusts on implementation issues. We have also produced a commissioning guide to help health professionals in England to commission an effective bariatric surgical service for the treatment of people with severe obesity.” 

NHS report

In addition, a new report from the NHS Information Centre entitled, “Statistics on obesity, physical activity and diet: England 2010” includes a new analysis of the health outcomes of people who are overweight and obese.

59% rise in the number of admissions with a primary diagnosis of obesity in 2008/09 compared with 2007/08

The report shows:

  • The number of people admitted to hospital with a primary diagnosis of obesity increased by nearly 60% between 2007/08 and 2008/09, rising from 5,020 to 7,990. The 2008/09 figure is eight times higher than in 1998/9 (950 people admitted). 

  • The number of prescription items dispensed to treat obesity was 1.28 million in 2008 – ten times higher than it was in 1999 (127,000).

There were 5,020 admissions with a primary diagnosis of obesity in 2007/08 but this rose to 7,990 in 2008/09 (a 59% rise), the data for England revealed. Previously published data on the number of prescriptions for obesity show there were 1.28 million items dispensed in 2008, ten times higher than the 1999 figure of 127,000.

NHS Information Centre chief executive Tim Straughan said: “This report highlights the impact of obesity not just on society, but on the NHS. The figures show a clear rise in hospital admissions, surgical procedures and drug therapies to help people tackle their obesity.”

Rise in obesity linked deaths

The furore over access to bariatric surgery comes as a recent analysis of death certificates by a University of Oxford team found a year-on-year increase in obesity-related deaths between 2000 and 2006. Moreover, recent government figures show 757 obesity related deaths in 2009, compared with 358 in 2000. The analysis of death certificate trends published in the European Journal of Public Health showed an average annual rise obesity mentions on death certificates of 8% for men and 4% for women. However, the researchers added that there were likely to be many more such deaths where obesity was not recorded.

The researchers said as obesity was rarely listed as the main cause of death, a simple snapshot of death certificates would not have picked up the rise. 

The marked increase was apparent when they included contributing causes of death in the analysis. Other figures recently released by the UK government showed more than 190 people under 65 died as a direct result of obesity in 2009 compared with 88 in 2000.

Dr David Haslam, Chair of The National Obesity Forum, said: “Bariatric surgery is amongst the most clinically-effective and cost-effective specialities in any field of medicine, preventing premature death, and transforming lives, whilst saving vast amounts of money for the NHS and the economy. Even the most cynical taxpayer should support bariatric surgery, alongside clinicians, in opposing the unethical and immoral barriers to surgery imposed by NHS purse-string holders.”

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