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UK: NHS commissioning groups restricting bariatric surgery
A freedom of information (FOI) request made to all NHS commissioning groups (CCGs) shows that several CCGs have adopted policies which attempt to ration bariatric surgery to the super-obese, and ignore official advice on who should be eligible for surgery. This has made it more difficult for overweight and obese people to get effective treatment to help them lose weight despite evidence that bariatric surgery is safe, effective and saves healthcare costs, according to the findings of a joint report from The British Obesity and Metabolic Surgery Society (BOMSS) and the Royal College of Surgeons (RCS).
For the survey the RCS contacted all 208 CCGs in England under the Freedom of Information regulations. 205 (98%) responded. Of those, 162 had not so far adopted their own policies for commissioning bariatric surgery, 36 had adopted policies that comply with NHS England and NICE guidance and seven had adopted policies that did not comply with the guidance.
Some CCGs either require patients to stop smoking or for patients to have a BMI>50, despite NHS England and the National Institute for Health and Care Excellence (NICE) stating that surgery is cost effective and should be considered for patients with a BMI>35 with a co-morbidity (a further medical condition) such as Type II diabetes, or a BMI>40 without a co-morbidity.
NHS England is currently delegating the commissioning of bariatric surgery to CCGs although most groups (79%) have yet to decide their own policies. In total, seven CCGs admit they are not complying with the NHS England and NICE guidance:
- East Riding and Vale of York CCGs said patients must have a BMI>50 before they will be considered for surgery
- Solihull and Wolverhampton impose the same condition but also add that they must have co-morbidities
- Mid-Essex is restricting treatment to non-smokers and;
- NE Essex says smokers must be referred to a cessation service before they can be considered
BOMSS and the RCS are warning this could harm patients and are demanding they revise their policies to bring them in line with the official guidelines. The report showed that most CCGs have not yet adopted their own bariatric surgery policies, but will have to do so by next month under a phased government NHS reform.
"Our survey reveals worrying evidence that some CCGs are effectively taking the law into their own hands and defying official guidance on surgical interventions which have been proved to help people with a serious medical condition and also save healthcare costs,” said Shaw Somers, Consultant surgeon and BOMSS President. "It typifies the second-class citizen manner in which bariatric patients seem to be viewed by some CCGs. We are calling on NHS England and NICE to make it clear to CCGs that they must comply with the guidelines on who is eligible for this safe and effective treatment, not try to ration it in a misguided attempt to save money in the short-term.”
BOMSS and the RCS make five recommendations to health bosses:
- The seven CCGs with arbitrary requirements for bariatric surgery should revise their policies in line with national clinical guidance
- NHS England should reiterate that access to NHS bariatric surgical treatment should be based on clinical need and uniform across the UK
- NICE and NHS England should continue to highlight the benefits of bariatric surgery
- NHS England should confirm that all CCGs will be responsible for commissioning bariatric surgery from 1 April to address the confusion over who is responsible; and
- NHS England should provide CCGs with clinical guidance for commissioning bariatric surgery, in advance of the transfer of responsibilities.
“Study after study shows bariatric surgery is highly effective, particularly in treating type 2 diabetes associated with obesity,” said Royal College of Surgeons President, Miss Clare Marx. “It is therefore astounding that commissioning groups are effectively indicating that obese patients should get even more obese before they will consider surgery. This makes no sense and contradicts our very strong public health messages about the benefits of losing weight. Bariatric surgery is a significant medical innovation which should be made available to those patients who meet criteria which NICE have considered and published.”
As well as calling on the seven CCGs to fall in line with guidance the RCS and BOMSS have pledged to review the policies of all CCGS once new commissioning rules are in place.