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Lack of referrals threatens UK bariatric surgery

Calls for implementation of NICE guidelines
Professor David Haslam, chairman of the National Obesity Forum

Following his recent comments to Channel Four News concerning access to bariatric surgery for under 16 year olds, Bariatric News speaks to Professor David Haslam, chairman of the National Obesity Forum about access to surgery and how a lack of referrals could drastically reduce the number of bariatric procedures in the UK.

In your experience, what is the scale of the obesity problem in the under 16s?

I am a GP and a bariatric physician and in both my roles I am seeing more and more children under the age of 16 presenting with obesity as the primary complaint or obesity related problems, such as joint pain and asthma. So we are seeing more obese children with more diverse problems. We are also seeing an increase in the number of patients diagnosed with type 2 diabetes - not so much in children - but certainly in younger and younger adults.

In my bariatric physician unit, we are seeing younger and younger people. Bearing in mind that funding is only allocated for obesity and diabetes or sleep apnoea that indicates that both the obesity and the comorbidities are getting worse. What we are seeing is the age going down and the size is going up.

How many children that you see should be considered for surgery?

I think it is still quite rare, but unfortunately the access to surgery is even rarer. I think it is something we are really quite blinkered about the obesity problem. While increasing exercise and reducing fizzy drinks and fast foods will work with some children who are obese, there is no doubt that for other children going on a diet for six weeks will just not work.

Colleagues have said to me that bariatric surgery is a desperate measure, and I agree. Desperate though it is, these children are in, or will soon be in, a very desperate situation. We know that these children are going to lose decades off their life expectancy and we cannot tolerate that.

Why do you believe that NICE should change their guidelines to include this age group

I think the current NICE guidelines for bariatric surgery are excellent; the problem is actually their implementation. The guidelines state: “Bariatric surgery is not generally recommended for children or young people. It should be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity”.

There are problems with commissioning bariatric services; I believe that some commissioners do not recognise that bariatric surgery is a life-saving procedure. There is also an issue with clinicians and primary care is not very good at referring patients for bariatric surgery. In an environment where commissioning guidelines prevent a lot of referrals anyway, the problem will only increase and access to surgery decreases.

There is a real problem: people do not recognise bariatric surgery is a safe and effective solution for patients who are morbidly obese and as a result the appropriate referrals are not made. My biggest fear is that this will lead to fewer and fewer bariatric procedures being performed to the stage where there will be no procedures performed on the NHS. Other countries in Europe, the United States, Australia, in South America; they all recognise the benefits of bariatric surgery not only to patients but also the cost-benefit to the health service. It is much cheaper to provide gastric bypass to pay for a lifetime of treating diabetes.

Unfortunately, the strange commissioning situation we find ourselves in means that rather than increase access, bariatric services will be so rationed that we will be doing a tiny fraction of the number of procedures that are required.

Are there any specific dangers related to bariatric surgery in children – either procedural or long-term?

Yes, there are potential issues such as hypoglycaemia and malnutrition, but then you also have to look at the benefits such as the resolution of diabetes, sleep apnoea and the number of decades a child has to live with those benefits. So the risks are greater in the respect that the child has greater time to live with them but they are balanced against the benefits.

Why is there is a lack of appreciation of the scale and long term health consequences of the obesity epidemic?

It is a lack of information, education and recognition. When we talk about children having bariatric surgery, as a GP you tell them to stop eating crisps, fizzy drinks, to take more exercise etc. But many GPs do not even consider surgery and I think we need to cross a line where as a profession we begin to consider surgery as an option in creating cases.

Do you think general practitioners fully-understand the obesity problem – has there been a change in recent years?

There is a problem with recognition, but there is also a fundamental problem with the healthcare system. The Quality Outcomes Framework does not incentivise GPs to do anything about obesity, let alone managing it. Currently, obese patients are placed on a register and we are paid for each patient on the register – that is a counter incentive. Where is the incentive for GPs to encourage patients to lose weight and come of the register?

What can be done about the obesity problem in terms of education?

Whenever I present lectures and talk to colleagues about their obese patients I subsequently get referrals because they all have patients who are obese, diabetic and are facing significant long-term health issues because of their weight. Once we communicate the message effectively and GPs understand the implications of treating obesity as the underlying problem, then we will see a difference. We have to start by educating 40,000 GPs and however many hundreds of thousands of nurses to be aware of the problem. The services are there, we just have to make our fellow healthcare professionals understand that obesity is treatable with the services we have available.

I am a member of the Obesity Strategy Review Group, and as a GP that is new. Professor Nick Finer, a bariatric physician at University College London, is also a member, as well as other clinicians, so I think things are changing in terms of awareness, especially at the Department of Health. Hopefully, the momentum is building and we will be able to educate, inform and create a greater awareness among all healthcare professionals and the public of the need to provide treatment for all obese patients.

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