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Care improvement recommendations

UK report calls for improved standards in bariatric centres

The report found that national standards of service both before and after surgery need improvement
Report finds only 32% of UK bariatric cases represent "good practice"
Authors say only 32% of cases have adequate follow-up post-surgery
Independent bariatric surgery providers criticised for advertising practices

A UK government body has issued a report calling for greater standards of care in bariatric surgery provision.

The report, “Too Lean A Service?”, released by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), centres its criticisms on centres which offer bariatric surgery as a “quick fix” solution, and do not perform acceptable pre-operative assessment or post-operative follow-up.

The report includes recommendations to use two-stage consent forms, provide multi-disciplinary teams, and ensure that patients have access to good post-operative care and a long-term follow-up plan. It also highlights the benefits of high-volume bariatric centres.

In total, the surgical advisors found that patients received a good standard of care in just 32% of cases; 60% of cases had scope for clinical and/or organisational improvement. Eight percent of cases were found to be less than satisfactory.

The study found that 29% of hospitals surveyed did not routinely follow-up patients by telephone. In total, the advisors found that 32% of cases did not receive adequate follow-up in the first six months after surgery. The report recommended that a clear, continuous long-term follow-up plan must be made clear for every patient, including input from surgeons, dietitians, GPs and nurses, as well as psychological or psychiatric input if the patient requires it.

Psychological care was also found to be insufficient: only 29% of cases demonstrated evidence of the patient receiving psychological input into their care.

The report recommends that patients are given a deferred two-stage consent procedure, where information about the potential risks of the operation are given by the doctor, and consent is provided by the patient at a later date. Consent forms were found not to contain appropriate information in 24% of cases.

Sixty seven percent of patients were discussed in a formal multi-disciplinary team meeting; however, 32% of multi-disciplinary teams did not meet the report’s standard of containing a surgeon, a dietitian, and a specialist nurse. The advisors said that 32% of the patients who were not seen by an anaesthetist prior to admission to surgery should have been.

Norman Williams, president of the Royal College of Surgeons, told the BBC that work was already underway to remedy the criticisms made in the report. "We will continue to work together with other health professionals in this area of surgery to ensure high standards of care and patient safety are maintained," he said.

Advertising

The report encourages professional organisations to issue standards of advertising for bariatric centres, following the lead of the American Society of Metabolic and Bariatric Surgeons. The authors write that many weight loss surgery advertisements in the UK would breach regulations and recommendations in other jurisdictions.

Out of 27 independent websites and 21 NHS Trusts found to be advertising a bariatric service in the UK, only 40% offered a clear explanation of the potential risks associated with the surgery, or the potential for failure. None of the independent providers gave information about the number of procedures performed annually; 13 out of 21 of the NHS institutions did.

The independent sector advertisements were found the present bariatric operations as quasi-cosmetic or quick-fix procedures, rather than highlighting their health-improvement benefits. The requirement for the patient to undergo lifestyle changes is normally obscured.

The report recommends standards advising against the use of superlatives or laudatory statements like “premier” or “best”, comparisons between surgeons or bariatric centres, misleading implications that independent centres are public bodies run under the safeguards of the NHS, or celebrity associations.

The Independent Healthcare Advisory Services, the representative trade body for most independent healthcare providers in the UK, has said that they will be working towards producing a code for independent hospitals and operators for the advertising of bariatric surgery.

Report

The NCEPOD report is the result of a two-year consultative process that examined the treatment and outcomes of around 500 patients who underwent a bariatric procedure in the British Isles between June and August 2010. It also reviewed the cases of 100 patients who needed to stay in critical care for three days or more during the same period.

The surgeon responsible for each selected patient was sent a questionnaire regarding the referral, inpatient care and follow-up. All hospitals performing bariatric surgery or admitting patients with complications leading from bariatric surgery were also sent questionnaires to establish the facilities and levels of care available.

The report is intended to be a qualitative complement to the National Bariatric Surgery Registry, which was launched in 2008 to measure surgery outcomes in the UK. (The National Bariatric Surgery Registry is operated by Dendrite Clinical Systems, the publishers of this newspaper.)

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