interviews

Treating severe and complex obesity

The evidence for bariatric surgery, when done well, is well-established, even if many commissioners rarely choose to fund it in accordance with NICE guidelines. But a new NCEPOD report suggests that pre- and post-operative care too often falls short of good practice, and many private providers are marketing the surgery inappropriately. NHE spoke to Professor Nick Finer of UCL Hospitals NHS FT, who chairs ESCO (Experts in Severe and Complex Obesity) and edits the journal Clinical Obesity.

The new NCEPOD (National Confidential Enquiry into Patient Outcome and Death) report into bariatric surgery, ‘Too lean a service?’, makes a number of key recommendations to improve patient outcomes and the patient experience, while noting: “Surgery has proved to be both clinically and cost effective and, as such, has been endorsed by NICE.”

Some of its recommendations will be familiar to anyone with a knowledge of the problems common to other surgical specialisms – for example, ensuring guidance is in place on the number of procedures surgeons should be performing annually.

It is “not for the occasional operator”, the report notes, while also urging more emphasis on psychological assessment and support from an early stage, a deferred two-stage consent process in all cases, and good-quality post-operative care, dietary guidance and post-discharge plan to be provided to the GP preferably within 24 hours.

The report also recommends that “a clear, continuous long-term follow-up plan must be made for every patient, [including] appropriate levels of informed surgical, dietitian, GP and nursing input”.

Professor Nick Finer chairs ESCO, founded to promote equitable access and viable funding for the treatment of people with severe and complex obesity on the NHS. ESCO welcomed the NCEPOD report and its recognition that bariatric surgical procedures are the most cost effective and best available treatments to tackle the obesity epidemic.

Discussing some of the problems highlighted by the NCEPOD report, and responsibility for tackling them, Professor Finer told us: “Ultimately it’s about the way bariatric surgery has been commissioned in much of the country, with referral direct to surgeons, who may be part of a multi-disciplinary team, but medical services for severely obese or complexly obese patients are very poor.

“That’s one of the key issues, and something that’s going to be addressed by the new commissioning guidelines next April: there will need to be a much greater medical and multidisciplinary input, with much better arrangements for longterm follow-up and care.”

A ‘cancer’ model not a ‘hernia’ model

He continued: “The difficulty is that many providers struggle at the moment. The national tariff is about £6,500.

“To provide a fully comprehensive medical service pre-, during and post-, plus the surgery itself, is, I think, not actually do-able at that price.

“What you have is the development of these services predominately through a surgical ‘hernia’ model, whereas actually this really ought to be based on a much more complex model, such as cancer: these are patients who need careful assessment and management pre-operative, peri-operatively and post-operatively.”

Prof Finer is keen to point out that bariatric surgery shouldn’t really be called ‘weight loss surgery’, as it is actually for treating things like diabetes – somewhere between 50% and 70% of people no longer need treatment for diabetes after bariatric surgery – and is associated with reductions in mortality from cancer, heart disease, and so on.

‘Not well understood’ by commissioners

Many health economics analyses suggest bariatric surgery tends to pay for itself within two to four years – but it remains a low priority for commissioners, and has recently become even less popular.

Prof Finer told us: “In fact, in many areas, the only route in is through low priorities panels.

“Commissioning is extremely variable. There is pretty clear evidence that in the last 6-9 months, most PCTs who were commissioning surgery have become more restrictive. In North London, until six months ago, if patients met the NICE criteria, and had been referred, they were automatically approved. Now, there is central approval.”

“It’s still not well understood by commissioners – there is some confusion between it and liposuction, cosmetic surgery…hopefully that is changing, but I’m not sure it fully is.

“I think there is a prejudice. If you’re a commissioner, and you have to make choices, the chances are that if you spend your money on bariatric surgery rather than cancer drugs, you will be vilified in your local paper. It’s an easy route to make it a low priority.”

He added: “One of the problems with a lot of the economic modelling is that even with bariatric surgery paying for itself in two to three years, most PCTs seem to be working on less than one year economic models. What other treatments are there where the cost of the treatment is recouped within two or three years? Over a fiveyear period, it’s probably economically dominant, and you could argue that it’s crazy not to do this.”

Professor Finer cited the recent abandonment of the American Look AHEAD study, which had found that intensive lifestyle interventions for obese people with type 2 diabetes could help them lose weight and had positive health benefits, but that their weight loss did not reduce the number of cardiovascular events. He also noted that potentially promising drugs were being rejected by regulators, saying that is another factor helping make the case for more bariatric surgery as a treatment method.

The role of ESCO

ESCO, a charity and campaigning group, was launched in 2009 by a disparate group including surgeons, physicians, gynaecologists, psychologists and patient members, to try to improve access for patients to surgery and other treatment and support for severe and complex obesity.

It has been trying to discover what’s going on with bariatric surgery around the country, primarily through freedom of information requests, and has been trying to provide evidence into the new commissioning arrangements. Professor Finer sits on the Department of Health obesity advisory group.

He said: “We’re about to go to press with a handbook to help primary care manage patients before, during and after surgery. That’s one of the other big problems: how do we educate primary care how to manage these patients.

“My view is that obesity is a bit like geriatrics was in the 1960s and 70s: when people started living into their 70s, 80s and 90s, medicine and commissioning and education needed to reflect that. Now there is hardly an area of medicine that’s not affected by obesity.”

NICE guidelines

The NCEPOD report, which examined both NHS and private procedures, notes: “The BMI range for the NHS funded group was 32-78 compared to 28-62 for privately funded patients. The median BMI was higher in the group of patients whose surgery was funded by the NHS (49 vs 42). This probably reflects the shortfall in NHS funding for bariatric surgery and the fact that commissioners have raised the bar for eligibility for surgery from that recommended by NICE (particularly with regard to a patient’s BMI).”

Professor Finer suggested that some patients getting surgery outside of NICE guidelines could get “less in the way of assessment before and follow-up afterwards”.

He added: “They may be people who are more likely to have either poorly understood the consent process, or may be being driven by more psychological issues.

“Any unit that does surgery knows there is a small percentage of patients who clearly have bad outcomes, either in terms of the effect on weight loss, or on their psychology, or on their quality of life, and that the real difficulty is that we have rather poor tools for predicting poor outcomes.

“The fact is that only 0.2% of people who are eligible under NICE guidelines, or less, actually get assessed for surgery. It’s a scandal. If you look at the variability across PCTs and specialist commissioning for criteria for surgery – last time we did this, there were something like 54 different criteria being applied across the 180 who responded. NICE, in that sense, has failed in terms of bariatric surgery, I would argue.”

He said the guidelines themselves are “certainly due for re-visiting”, especially as regards patients with type 2 diabetes. He said: “The International Diabetes Federation’s recommendation, which came out a year or two ago, is that patients with type 2 diabetes and a BMI of 30+ should be eligible. That’s based on good quality data and randomised trials.”

But he added: “My own view is that one of the problems with NICE, and indeed with commissioning, is that it is very BMI-centric. We know, particularly at lower levels of BMI, that it relates very poorly both to the morbidity of patients, and, at a more physiological level, to what their excess fat is. BMI is great for epidemiological studies, but probably not so good for individual decisions.”

Patient safety

Professor Finer backed the messages in the NCEPOD report around patient safety and clinical quality. He said: “There’s no doubt that this is surgery that is safer done by surgeons who do volume surgery: it is not a type of surgery for people who ‘dabble’.

“Most of the recommendations are that they should be doing at least 50, and ideally at least 100 procedures a year. If you go back a year or so, most units were doing that. But there has been a clear downturn in the number of cases being commissioned, and I suspect there are now units where there are surgeons who are not meeting those requirements.”

On accreditation, he said the value of the existing accreditation schemes in the US, Europe, and internationally is “up for question”, but added: “It’s probably sensible that there should be mandatory accreditation not of the surgeon but of the unit.”

Another ESCO spokesman, Peter Small, said: “It’s clear that some of the services being provided to patients fall short of what ESCO would consider best practice. ESCO is wellplaced to offer the new CCGs support in making sure the most effective obesity treatment packages are put in place for patients.”

Follow-up data

Professor Finer said getting good quality followup data after bariatric procedures is difficult, and noted that it’s an unusual type of surgery in the first place, since it’s about deliberately tampering with a person’s body “for a greater good”, rather than fixing something that’s going wrong or removing something that shouldn’t be there.

He continued: “It is absolutely critical that patients remain under follow-up. Again that comes back to commissioning because up until now, there’s been a huge overt or covert requirement from the commissioners not to follow patients up. Most places are told they should be discharging patients after one year or two, and most are having their service judged by new-to-follow-up ratios, usually based on a ratio of around 2.6 follow-ups to 1 new. That doesn’t even cover the first year of follow-up.

“A good thing that will come out of this NCEPOD report, and hopefully new commissioning, will be to bring some rationality into not just the acute peri-operative but the whole-life course of patients being considered for and having surgery.”

Advertising

The NCEPOD report is critical of the way weight loss surgery is advertised in some cases, saying it’s “directed toward privately funded patients on the basis not only of health gain, but also body image and lifestyle choice”, in which case the ethical and professional considerations “are more closely aligned to the issues around cosmetic surgery”.

It notes: “Independent sector advertisements seem to present bariatric procedures as quasicosmetic, quick-fix procedures rather than highlighting the improvement or potential risk reduction of obesity-related comorbidities.”

Its recommendation is that “professional associations and regulators should agree a code of conduct for advertisements for weight loss surgery in the UK which safeguard and appropriately advise patients seeking this increasingly popular method of weight control”.

Prof Finer told us: “One of the problems is that many patients are being literally driven into the private sector by the lack of availability of a treatment that NICE has recommended locally – it’s disgusting.

“There are people who are in it to make money from private contracting, who are interested in short-term results, who will be here today and – if it doesn’t make money or if they’ve saturated the market – gone tomorrow. Will the private set-ups who are doing this be around in five years time to see their patients? Or will the NHS have to pick up the sequelae of patients who they would probably not have operated on in the first place?”

He suggested the GMC and Advertising Standards Authority both ought to be more involved in this area.

“But the root cause is this – there wouldn’t be a need for the private sector, or only a very small one, if the NHS was meeting its obligations.”