How will WLS weather the cuts in the health service?
November 10, 2010
In January 2010 a Conference held at the Royal College of Surgeons heard about of 'unfair and unethical' access to NHS weight loss surgery. In the current climate Strategic Health Authorities have been axed and will disappear next year and commissioning of most health services will pass to GP consortia, although WLS will continue to be commissioned on a regional basis.At that time the College said that access to NHS weight-loss surgery is 'inconsistent, unethical and completely dependent on geographical location', say senior surgeons at a conference of UK bariatric surgeons held in January 2010 at the Royal College of Surgeons of England. Is this likely to get worse with these cuts even though Government has stated several times that "frontline" services will not be cut? Let's look at the situation to date:
Constraints on NHS funding mean that in some areas NHS decision makers are opting to ignore professional guidelines and are denying patients' access to surgery. In others, patients who already met the criteria were forced to wait until either they become more obese or developed life-threatening illness like diabetes or stroke. The Royal College of Surgeons called for consistency and transparency across the NHS so that patients are clear about what they are entitled to and doctors can treat all patients equally.
Those of us involved in WLS know that according to the NHS Constitution published in 2009 morbidly obese patients have a legal right to be properly assessed for weight loss surgery under guidelines set out by the National Institute for Health and Clinical Excellence. (NICE). However, we are also painfully aware (and the Royal College research has demonstrated) that while some Primary Care Trusts adhere to the guidelines, others are raising the bar so that only the most extremely ill patients - those with a BMI of 50 or 60 with obesity related illness - are being referred for surgery. Quite simply there is no clinical evidence to support this practice. In fact, evidence suggests that not only do these patients have less to gain from surgery but are far more likely to suffer serious complications.
The College conducted an anonymous survey of UK bariatric surgeons which showed that:
- Approximately two thirds of surgeons said patients who are eligible under NICE guidelines are refused surgery in their centres.
- Criteria for surgery varies dramatically depending on geographical location and within the same Strategic Health Authorities.
- Some centres are treating patients with referrals from multiple Primary Care Trusts (PCTs) with different eligibility criteria meaning that patients with a BMI of 60 + are being refused surgery in the same hospitals that are treating patients with a BMI of 40 or less.
- Some Primary Care Trusts are refusing to commission any obesity surgery.
At the time they called for the Department of Health to invest in a long term strategy to ensure that all patients have equal access to treatment delivered by experienced multi-disciplinary teams working out of properly equipped centres that can offer a full specialist assessment, an appropriate treatment and provide safe long-term follow up and emergency re-admission. The immediate response from the Department of Health delivered via the media was to suggest that other more important health strategies would have to wait if WLS was funded. The very emotive phrase was used "well do you want to take funding away from a cancer patient?" Interestingly this appears to have filtered down to local press, trusts and medical professionals so that the false equation that increasing investment in WLS would decrease investment in cancer has taken root. Ironic in light of the evidence that WLS leads to a decrease in several cancers. At the recent WLSinfo Annual General Meeting, on 16th October, several members reported annoyed queries and statements from Medical secretaries when asking about delays in their approved Plastics procedures of "well, it's not cancer, you'll just have to wait!" .
The increasing use of this strategy used which appears to use the public's existing discrimination of obese individuals to vilify those trying to access treatments they are legally entitled to is unlikely to improve in an increasingly tight economic environment.
In January Bariatric surgeon and RCS Director of Education, Professor Mike Larvin said: "NICE guidelines are meant to signal the end of postcode lotteries, yet local commissioning groups are choosing not to deliver on obesity surgery. In many regions the threshold criteria are being raised to save money in the short term meaning patients are being denied life-saving and cost effective treatments and effectively encouraged to eat more in order to gain a more risky operation further down the line."
There is currently no evidence to suggest any improvement other than small local increases in access to this life-changing and life-saving surgeries.
Mr Alberic Fiennes, President of the British Obesity and Metabolic Surgical Society (BOMSS), said at the time: "We recognise the difficulties faced in dealing with a 'new' disease of epidemic proportions but to limit surgery to the most severely obese is unfair and short-sighted and against basic professional ethics. It is also contrary to strategies that are standard for diseases that overwhelm resources." What this eminent surgeon is saying is as emotive for some as the false cancer funding equation, because the standard protocol for scarce NHS resources is to limit the treatment to those best able mentally, physically and socially to benefit from them. This would prioritise the younger, healthier patients with access to good support
Another leading expert in the field commented "Bariatric surgery is amongst the most clinically-effective and cost-effective specialities in any field of medicine, preventing premature death, and transforming lives, whilst saving vast amounts of money for the NHS and the economy. Even the most cynical taxpayer should support bariatric surgery, alongside clinicians, in opposing the unethical and immoral barriers to surgery imposed by NHS purse-string holders." Dr David Haslam, Chair of The National Obesity Forum. However no changes have been noted to date.
Ken Clare Chairman of WLSinfo said "We see and hear the human effects of this problem every day from our members. We have real concerns that given the public perception of obesity as a self inflicted problem fueled by the negative stance in the media that the government will not implement necessary changes.
A failure to adequately treat obesity will have far reaching health economic and social consequences for the individual as well as the whole of society."
Whatever the government has said about ring-fencing NHS funding, we have already seen cuts being implemented by SHAs in 2010 with more promised. Most SHAs have told the Deaneries (the bodies responsibilble for Post-Graduate Meducal Education and Training of junior doctors) to cut up to 40% of their budgets over three years. Most Dean's believe they will have to cut training posts to do this. Even if spendning on front-line services is not cut, the fact that it will not increase with inflation is already an effective year on year cut. The maths is pretty basic. For example drug costs go up but they must come from the same pot of money so do we but fewer drugs or cut other services?
Patients attempting to access WLS over the next few years are likely to have to wait longer and people waiting for bariatric surgery will probably see even more of the media false equation with cancer funding.
Jaci Joyce