The National Institute for Health and Clinical Excellence said September 9 that not enough bariatric surgery is being performed in England. The agency cited a report commissioned by the Royal College of Surgeons, showing that only a small fraction of people eligible for weight loss surgery in England are actually receiving it.
About a quarter of Britons are obese, with obesity a rising trend despite numerous public health campaigns aimed at addressing it. Obesity-related disorders cost the National Health Service an estimated £4.3 billion annually, according to the U.K. Department of Health. Yet the report commissioned by the surgeons warns that English primary care trusts (PCT) are not following established clinical guidelines on bariatric surgery, which, if followed, would reduce health care costs systematically.
“If NICE guidelines on bariatric surgery were followed, direct NHS cost savings would be around £56 million a year,” NICE said in a press statement about the report. “PCTs are either ignoring NICE guidelines and rationing care for all but the most severely ill patients, or offering no service at all.”
The NICE statement stood in some contrast to the U.K. Department of Health’s response to the report, in which Public Health Minister Anne Milton said surgery “should always be a last resort” and that “it is up to individual trusts to commission a range of services to meet their local community’s needs.”
NICE officials contacted said they refused to speculate as to why their agency’s obesity guideline wasn’t being followed. However, the agency’s clinical guidelines, which include its obesity and bariatric surgery guideline, differ from its technical appraisals in that PCTs are not mandated to adhere to them.
The surgeons’ report – carried out by the Office of Health Economics, an independent research firm, and published Sept 8. – estimated that as many as many as 140,000 people in England qualified for bariatric surgery in 2009 and 2010 under guidelines published by NICE. Yet the actual number of surgeries performed at trusts in England in that time period was 3,607. This, the report concluded, was largely the result of different practices among different primary care trusts: “Adherence is generally sub-optimal but the number of procedures commissioned by PCTs ranged from one to 194 in 2009-10,” the report stated, “indicating a wide variation in practice.”
The 2006 NICE clinical guideline on obesity offers tiered recommendations on interventions based on the severity of a patient’s disease and the presence of comorbidities, with surgery as a last option following lifestyle and other interventions. According to the guideline, people with a body mass index of 40 or higher, and who have failed to lose weight through other means, qualify for surgery. People with a body mass index as low as 35 may quality for surgery if they have comorbidities, such as diabetes or high blood pressure.
Yet the trusts themselves seem to have decided to make surgery rarer, implementing the guidelines more stringently, according to the surgeons’ report, which used findings from other reports, a self-reported questionnaire to all 152 PCTs in England about their practices (81 responses were considered in the analysis), and additional records to gain a picture of how much bariatric surgery was really being performed.
The surveys revealed that the self-rationing was likely to continue in the current cost-cutting mood: “Although only one in ten PCTs that responded said that they would be reducing funding for obesity services, one third said that they would be applying the NICE guidance more stringently and none that the guidance would be applied less stringently,” the report said.