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Surgical provision

Wales: Eat more to qualify for bariatric surgery

Fewer than 70 annual procedures
RCP said it had concerns at a “complete failure” of Local Health Boards

An inquiry in Wales has found a 'perverse incentive' for obese patients to put on further weight to meet the requirements for 'poorly funded' bariatric surgery.

Although an all-Wales anti-obesity strategy was launched more than three years ago, the report found that funding for anti-obesity and bariatric treatments were non-existent.

Dr Nadim Haboubi, chair of the National Obesity Forum for Wales, said there is evidence that the current rate of bariatric surgery operations meant only 0.1% of qualifying very obese patients were receiving surgery in Wales. As a result of the poor resources and funding, obese patients are attempting to increase their weight so they qualify for surgery

He added that the only unit in the country for specialist weight management services was “poorly resourced and unsupported” and there was a “desperate need for expansion” through other parts of Wales.

The Royal College of Surgeons Professional Affairs Board in Wales and the British Obesity and Metabolic Surgery Society (BOMSS) said “unfair and short-sighted” qualifying criteria meant there was a “perverse” incentive for obese patients to raise their BMI) to become eligible for surgery.

“The Royal College of Surgeons and BOMSS have serious concerns that the 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. We believe to limit surgery to the most severely obese is unfair and short-sighted.”

Present restrictions require patients to have a BMI higher than 50 and additional comorbidity/ies, despite NICE guidelines stipulating a BMI35.

The warning was echoed by the Royal College of Anaesthetists Advisory Board for Wales, which said a requirement for patients to have a BMI higher than 50 and suffer obesity-related conditions, meant those that didn’t “make the grade” may look to hike their BMI further to qualify.

The calls come as Wales’ National Assembly’s Health and Social Care Committee prepares to conduct an inquiry into the availability of bariatric services in the country and is likely to re-ignite the debate over whether such services should be funded by the Welsh NHS.

A host of other organisations, including the Royal College of Physicians (RCP), complained of a failure to provide anti-obesity services throughout the four tiers set out in the Welsh Government’s All-Wales Obesity Pathway (AWOP), established in 2010, including for the most serious cases. This is despite mounting evidence Wales has among the worst obesity rates in the world.

The RCP said it had concerns at a “complete failure” of Local Health Boards to develop Level Three and Four services which provide intensive, specialist, non-surgical multidisciplinary obesity services for those failing to maintain a healthy weight from earlier interventions.

In its evidence, it said: “The provision of bariatric surgery within Wales is far from being NICE-compliant. The service is based in one specialist centre in South Wales while patients from North Wales are operated on in England.

“There is a clear need for an additional centre in North Wales. Furthermore, patients are required to be substantially more obese in Wales to qualify for surgery under WHSCC rules.  The service is severely rationed to fewer than 70 patients a year. To be NICE compliant, with its population, surgeons in Wales should be carrying out 350 operations a year. Bariatric surgery can improve morbidity, mortality, economic and social wellbeing, and the long-term and intermediate cost benefits to a healthcare system are clear.”

It claimed there was “very little investment” in either pre-surgery specialist services (Level Three) or surgical units (Level Four) across Wales, it said, and warned there was a “clear need” for bariatric surgery facility in North Wales, with patients currently having to travel to a bariatric unit in Salford, Greater Manchester, for NHS-funded care.

The Welsh Health Specialised Services Committee (WHSSC) – independent of Welsh Government and formed across all of Wales’ seven local health boards – said it was looking to relax the criteria in this commissioning year, but admitted there was a lack of specialised weight management services before surgery.

Estimated costs to the Welsh NHS of obesity-related conditions total £73m and bariatric surgery is touted as a major cost-saving mechanism.

The Welsh Association for Gastroenterology and Endoscopy (Wage) added the guidelines for access to surgery in Wales were so stringent that “only very advanced cases are being funded”.

It added: “Unfortunately, such patients already have organ damage secondary to their Type 2 diabetes and hypertension consequent upon morbid obesity, and are thus more likely to develop serious post-operative complications.

“While bariatric surgery is an important part of the obesity pathway, the provision of such surgery cannot be considered in isolation and there is a need for a coordinated, multi-disciplinary approach across the whole obesity pathway to address the problem of obesity,” said a Welsh Government spokesman. “The most cost effective means of providing services for overweight and obese people in Wales is a holistic approach to change the behaviour of the population as a whole in relation to diet, exercise, and lifestyles in general.

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British Obesity and Metabolic Surgery Society

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