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UK needs 50,000 bariatric procedures a year

Despite the obesity epidemic barriers to surgery remain
Bariatric procedures are down although surgery shown to be cost-effective

The NHS should significantly increase rates of bariatric surgery to 50,000 a year, closer to the European average, to bring major health benefits for patients and help reduce healthcare costs in the long term, according to a paper published in The BMJ. The paper states that between 2011-12 and 2014-15, the number of bariatric operations performed on the NHS fell by 31% - from 8,794 to 6,032, and less than 1% of those who could benefit get treatment. This is in stark contrast to provision in many European Union countries, as the UK currently ranks 13th out of 17 for EU countries and sixth in the G8 countries for rates of bariatric surgery. This is despite the UK having the second highest rate of obesity in Europe, and sixth internationally.

In the paper, ‘Why the NHS should do more bariatric surgery; how much should we do?’, the authors examine the clinical and cost effectiveness of bariatric surgery and examine the barriers to access.

“Increasing surgery rates to 50 000 a year, which is closer to the European average, could have major benefits for patient health and reduce direct healthcare expenditure within two years.”

With regards to the effectiveness of surgery the cite the Swedish Obese Subjects study (SOS), which reported weight loss being maintained for 20 years, with glycaemic control improved for at least ten years after surgery. In addition, surgical patients were more likely to go into glycaemic remission of diabetes and fewer patients progressed from pre-diabetes to diabetes. This study also noted that the average weight loss was 25-35% of body weight (usually at least 15 kg) after one year for patients who are severely obese and 15-25% after 20 years. This is compared with an average 7% weight loss achieved by patients undergoing an intensive lifestyle weight management programme or weight loss drugs.

Furthermore, data from the UK National Bariatric Surgical Registry showed that over 3,000 patients with diabetes who had bariatric surgery (between 2011 and 2013), some 65% had acceptable glycaemic control without medication after surgery.

The authors also state that bariatric surgery is cost effective compared with non-surgical treatments and a UK health technology assessment concluded that bariatric surgery for patients with BMI≥40 results in an incremental cost effectiveness ratio for of between £2000 and £4000 per quality adjusted life year (QALY) gained over 20 years. In addition, the diabetic and patients with BMI 30-39 the incremental cost effective ratio was £1367 per QALY gained. This is substantially below the £20,000 per QALY threshold for cost effectiveness used by the National Institute for Health and Care Excellence (NICE). They also argue that the cost of surgery is justified as a diabetic will need prescriptions, this costs alone is recouped within three years of surgery

Eligibility

According to guidance from the National Institute for Health and Care Excellence, surgery should be considered for the “severe obesity in whom all non-surgical measures have been tried without achieving or maintaining adequate weight loss” – this equates to some 1.6 million people in the UK who have a BMI>40.14.

In addition, there are another half a million people with diabetes and other obesity related disease with BMI≥35. An extra 60,000 people a year reach a BMI40 and the number of people with type 2 diabetes has also increased by 60% over the past decade (to 3.3 million or 5% of the adult population), with 9.5% of adults predicted to have the condition by 2030 (190,000 new patients each year). Despite this, bariatric surgery procedures have reduced dramatically in the UK, with no NHS operations in Northern Ireland and few in Wales and Scotland.

“Given the severity of the problem, it seems urgent to consider the potential barriers to surgery,” the authors note. 

Barriers

They state that one of the key barriers to surgery is the tiered pathway approach to surgery, under which general practitioners (GPs) are unable to refer patients directly to surgical services (Table 1).

Table 1

Tier

Intervention

Barriers

1

Societal interventions to enhance weight loss
(eg, food tax, encouraging walking)

Easy access to high calorie, inexpensive food
Sedentary lifestyle accepted

2

Primary care provision of advice or referral to community groups for lifestyle interventions
(eg, dieting)

Patients reluctant to ask GPs for help for multiple reasons
GPs don’t like to mention weight

3

Secondary care based medical management
(eg, dietary advice, medication)

Services not commissioned
Patients disengage with long referral pathway
Patients not referred for surgery

4

Multidisciplinary team selection for bariatric surgery with follow-up for 2 years

Insufficient operations commissioned
Inadequate follow-up provided

In addition, the thresholds for surgery are unclear varies between regions despite NICE guidance, and the disparities in care are only likely to increase as from April 2016 local commissioning groups are free to pursue other obesity treatment strategies. This means that chances of treatment depends not on a patient’s need, but on their location.

“Increasing surgery rates to 50 000 a year, which is closer to the European average, could have major benefits for patient health and reduce direct healthcare expenditure within two years, in addition to cost savings in the future from reduced treatment costs,” the authors write. “To achieve this health workers need to leave prejudice behind, promote bariatric surgery, and offer it to people who are unable to succeed with non-operative measures…In addition, GPs and commissioners need to recognise the health benefits gained from bariatric surgery (and the cost savings). This will facilitate better provision of secondary care services. We recommend combining provision of secondary care medical and surgical management so that patients have access to surgical assessment earlier.”

“Provision of more surgery also requires better long term support and nutritional follow-up (key to the success of surgery),” the authors write. “Development of obesity or metabolic care services for surgical follow-up in general practice could also improve care for people not wanting surgery…However, a renewed active focus on this large group of patients could limit future costs of treating complications related to obesity and diabetes.”

The authors of this paper were, Mr Richard Welbourn (Musgrove Park Hospital, Taunton, UK), Professor Carel W le Roux, (Conway Institute, University College Dublin, Ireland), Dr Amanda Owen-Smith (University of Bristol, Bristol), Dr Sarah Wordsworth (University of Oxford, Oxford) and Professor Jane M Blazeby (University of Bristol).

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