The Provision of Bariatric Surgery in the United Kingdom—PAST, PRESENT AND FUTURE CONSIDERATIONS: THE ROAD TO EXCELLENCE

by Sherif Hakky, MBBS, MSc, MRCS;
Matthew Thompson, MBBS, BSc; and
Ahmed R. Ahmed, MBBS, BSc(Hons), FRCS

Department of Bariatric Surgery, Imperial College Healthcare, Charing Cross Hospital,  London, United Kingdom

INTRODUCTION
Bariatric surgery in the United Kingdom (UK) has grown and adapted over recent years to meet the new demands imposed by an ever-increasing rise in clinical obesity. This process has been promulgated through growing evidence of the clinical benefits of surgery as well as advantageous health economics favoring surgery. The lack of successful lifestyle and pharmaceutical therapies to treat obesity along with the financial burden imposed on a free access healthcare system (the National Health Service—NHS) through obesity-related disease have further perpetuated these changes.
There are many success stories and a mounting evidence base that make bariatric surgery an exciting field in the UK at present.
There exists the potential to cure diabetes, hypertension, hypercholesterolemia and sleep apnea while also dramatically reducing the risk of a large number of other diseases including some cancers thus providing an overall survival benefit.[1–3] This is something no other speciality can boast.

With the United States being the clear forerunner in terms of the number of bariatric procedures performed, the UK is receiving recognition for its work with Imperial College Healthcare NHS Trust recently becoming recognized as an International Bariatric Surgery Centres of Excellence outside the US. Bariatric services in the UK have significant differences in the way they are funded and delivered. The aim of this article is to provide a brief overview of the current state of practice in the UK.

POPULATION
According to the latest Lifestyle Statistics published by the Information Centre for the NHS, 24 percent of adults (aged 16 or older) in England are classified as obese.[4] This has nearly doubled since 1993. Women are more likely to be morbidly obese (3% compared to the 1% in men). The implications are that 21 percent of male citizens and 23 percent of female citizens are classed as being at very high risk of obesity- related health disease. The burden of diabetes is high with more than two million suffering from this chronic disease.[5] In fact, in these over 35 years old, an increased waist circumference was found to double the risk of diabetes in men and make diabetes four times more likely in women.[6] This epidemic has led to over 17,000 hospital clinic appointments with obesity as the primary diagnosis and over a million prescriptions directly related to the treatment of obesity. Children in the UK have similar incidence of obesity as adults with 16 percent of those aged 2 to 16 now classified as clinically obese. Moreover, a large international study on pediatric obesity suggests that this problem is only going to impact more on the nation’s health by the end of the decade.[7]

ACCESS TO CARE: THE PRIVATE MARKET
In the UK, medical insurance companies do not cover bariatric procedures because obesity is considered a chronic disease. Thus, patients wanting to have bariatric surgery have to fund it themselves. The cost of a gastric bypass in the private sector is around $17,000. Many cannot afford this and choose to travel to neighboring countries in Europe where they can get more competitively priced bariatric surgery. However this leads to problems with follow up as these European centers, though offering a cheaper option with minimal waiting times, are without appropriate provision for long-term follow up. Furthermore any complication arising from the index operation is not covered, often leaving patients to fend for themselves, usually culminating in a fallback on the National Health Service (NHS).

ACCESS TO CARE: THE PUBLIC (NHS) MARKET
The NHS is the national healthcare system in England that is funded by the taxpayer through the Department of Health. The NHS in England alone caters to a population of more than 50 million and employs more than 1.3 million people.8 The NHS is thus one of the world’s top five employers. The principle fund holders of the NHS are the Primary Care Trusts (PCTs), which are divided into groups of family care physicians (General Practitioners—GPs). PCTs are responsible for commissioning healthcare from hospitals. The Department of Health is responsible for allocating each PCT a specific budget guided by the local needs and size of the population served by the PCT. It is the responsibility of the PCT to allocate this budget according to the local population’s health requirements. Thus, the PCTs in each region of the UK decide how many patients will undergo bariatric surgery and then purchase this service from the providing hospitals.

To help PCTs make decisions regarding who should get treatment and its nature, the Department of Health has a separate organization. All treatments undergo assessment by the National Institute for Health and Clinical Excellence (NICE), a special authority of the NHS that takes into consideration not only the best possible outcome for the patient but the cost effectiveness of the treatment regimen. NICE publishes clinical guidelines for the assessed treatments.

The NICE guidelines of 20029 and updated in 200610 were largely based on the US National Institute of Health guidelines[11] and state that bariatric surgery should be considered a treatment option for adults with obesity if the following criteria are fulfilled:
• Patients who have BMIs of 40kg/m2 or more, or between 35kg/m2 and 40kg/m2 with other significant disease that could be improved if they lost weight
• All appropriate nonsurgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least six months
• Patients are receiving or will receive management in a specialist obesity service
• Patients are generally fit for anaesthesia and surgery
• Patients commit to the need for long-term follow up.
Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50kg/m2 in whom surgical intervention is considered appropriate.

NICE conservatively estimated in 2006 that there was an eligible and growing patient cohort of 256,000 patients in the UK with only 1,500 NHS-funded bariatric surgeries.10 The statistics are comparable with other European countries where the UK shortfall becomes even more noticeable: In Belgium, over 70 bariatric procedures per 100,000 inhabitants are performed annually as opposed to 6.3 per 100,000 inhabitants in the UK in 2006.12 The current burden of morbid obesity in the UK is approximately 720,000 patients who meet NICE criteria for eligibility for surgery. Last year, only 4,000 operations for morbid obesity were performed in the public and private sector combined.[13] One explanation is that despite the 2002 NICE guidelines being released with clear indications for bariatric surgery, many patients were being denied access to surgery. As recently as 2005, it was found that 19 percent of PCTs were not providing any funding for obesity surgery at all.[14] The problem remains that a NICE guideline is simply a guideline and not enforceable legally. There have been a few cases where patients meeting the criteria for surgery have not been referred for surgery by their PCT and legal action has been threatened.[15]

One study that looked at the uptake of obesity surgery across the UK between 1996 and 2005 found that access to bariatric surgery varied considerably between regions and did not reflect local obesity and comorbidity rates in these areas.[16] The conclusion was obvious yet critical: a national framework was needed to implement nationwide access, monitor the progress of obesity surgery, and ensure long-term patient follow up with auditing of outcomes. This is still undergoing development currently.

BREAKING EVEN
The Department of Health in the UK realizes that although the upfront cost of bariatric surgery may be high, there is increasing evidence of the financial benefits in addition to the personal health benefits of surgery in the long-term. The areas of financial gain are possible to appreciate when looking at a Canadian study[17] that compared 1,035 patients who underwent bariatric surgery with a control group of 5,746 and followed them for five years. This study showed that the bariatric surgery patients had significant risk reductions for developing cardiovascular, cancer, endocrine, infectious, and psychiatric disorders compared with the control group, and more importantly a significantly lower mortality rate of 0.68 percent among the bariatric surgery group compared to 6.17 percent in the controls. Another study from Australia showed that an average of 75 percent of patients were taken off their type 2 diabetes (T2DM) medications three years post-operatively.[18] The cost of managing T2DM alone in the UK is approximately $4,000 per person per year19 and does not take into consideration the cost of treating any of its numerous complications. A study conducted locally in a West London bariatric center showed a trend of decreased total costs post-surgery when the entire patient healthcare regimen is considered. Preoperative total healthcare cost was 1.58 times more expensive than post-surgery. More specifically, cardiovascular treatment cost fell by 70 percent (p=0.01), and, even more significantly, the cost of diabetic treatment fell by 80 percent from $1,785 to $315 (p=0.06) per annum.[20] Thus, the economic benefits to a socialized healthcare system are clear.

One large UK review[21] provided a net cost per quality-adjusted life year (QALY) gained as a measure of the effect of surgery on disease burden. A number of studies were assessed that analyzed the pre- and post-treatment quality of life scores for patients with obesity. The results were strongly in favour of surgery as a cost-effective alternative to traditional weight loss management strategies. The national economic burden of time off work and disability benefits are not even taken into account in the majority of studies but must be considered when assessing the feasibility of bariatric surgery in various populations. A study in the UK concluded that more patients return to paid employment after bariatric surgery, and that the number of weekly hours they work increased coupled with an increased ability to perform tasks and less limitation of the type of work done compared to the same population prior to having bariatric surgery. It also found that patients after surgery claimed fewer state benefits including disability allowance and required a decreased package of care.[22]

IMPLEMENTATION
Despite the proven cost effectiveness of bariatric surgery, there have been delays with implementation of a nationwide strategy for bariatric surgery in the UK. Currently, access to bariatric surgery in the UK is divided regionally. A number of hospitals offering bariatric surgery in the same region compete with one another to achieve the status of preferred provider for that area. This exercise involves submitting applications followed by a site visit by the regions PCT commissioners. Selected preferred providers should receive the bulk of NHS bariatric surgery workload.

Most surgeons practicing bariatric surgery in the UK are upper gastrointestinal surgeons who are self taught or have attended international bariatric surgery courses. In the UK, there are currently only two US bariatric fellowship-trained surgeons. However, the number of bariatric surgery fellowships and courses on offer in the UK is rising. It is difficult to get figures for the comparative numbers of the procedures performed but it is believed that the numbers of gastric bypass are still lagging behind the gastric bands though this trend appears to be changing.

THE UK BARIATRIC SURGERY REGISTRY
In January 2009, collaboration between the ALSGBI (Association of Laparoscopic Surgeons of Great Britain and Ireland), AUGIS (Association of Upper Gastrointestinal Surgery) and BOMSS (British Obesity and Metabolic Surgery Society) resulted in the launch of the National Bariatric Surgery Registry (www.nbsr.org.uk).[23] The aim is to provide a nationwide online record of patient outcomes from which an evidence base can eventually be established. Over a 1,000 patient records were entered within the first 12 weeks after launch.

POST-OPERATIVE AND LONG-TERM FOLLOW UP
With the massively increasing demand for bariatric surgery coupled with the need to allocate scarce resources, it will be very difficult for hospitals in the NHS to provide lifelong follow up. Currently a system where the referring GP practice will follow up the post-operative patient using established protocols are being explored. The GPs would then input patient data to a shared database and would contact the hospital if specialized help is necessary.

FUTURE CONSIDERATIONS
There is currently an expanding generation of young surgeons at the resident level who are seeking bariatric surgery training with established UK bariatric surgeons,  and this will subsequently lead to an increase in the number of trained bariatric surgeons. There is also an increased desire by NHS hospitals to gain international accreditation through societies, such as ASMBS and IFSO, to ensure a high quality of service is provided to UK patients. Increasing awareness to the benefits of bariatric surgery by patients, PCTs, and the media will ensure that bariatric surgery in the UK continues to grow and prosper.

References
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Category: International Perspective, Past Articles