Incentive paradox dogs weight loss procedures

Surgery can help obese people lose a significant amount of weight - and reduce their risks of dying from chronic conditions.

But, despite National Institute for Health and Clinical Excellence guidance in place since 2002, many patients in England will struggle to get treatment on the NHS.

NICE recommends surgery is considered for patients with a body mass index of over 40, where appropriate non-surgical measures have been tried but have not resulted in significant weight loss. Patients with co-morbidities could be offered it at a lower BMI of 35 plus - and those with a BMI of over 50 should be offered it as a “first line” option.

A survey by the British Obesity Surgery Patient Association in early 2008 showed enormous variation in criteria among English primary care trusts. A significant proportion followed NICE guidelines but others had criteria of BMI 65 or over, five years’ obesity, or five years of attempted weight reduction. In many cases, people with co-morbidities would qualify for treatment at a lower weight.

This created the bizarre situation where the easiest way to get treatment was to put on weight or develop the very conditions the surgery was meant to help prevent; a perverse incentive.

The position may be even worse in other parts of the UK: the Royal College of Physicians in Edinburgh recently highlighted the difficulties in getting obesity surgery in Scotland, with only around 300 procedures carried out a year - half of these on the NHS - despite 24,000 eligible patients willing to undergo treatment.

BOSPA says patients are frequently frustrated by a system which seems to make it as complicated as possible to access surgery - and can face long waits to get into weight management clinics before they can go forward for surgery.

Shaw Somers, a bariatric surgeon and council member of the British Obesity and Metabolic Surgery Society, says surgery is sometimes refused because a package of care cannot be provided locally, and patients have to get prior approval for treatment.

“There is a blatant postcode lottery,” he says.

Highest BMIs

Over the past couple of years specialist commissioning groups have increasingly begun to standardise criteria across strategic health authority areas. Some are moving all primary care trusts towards the NICE criteria - but often over a long timescale. One has moved away from them.

East Midlands specialised commissioning group has adopted a criteria of BMI of 50-plus or 45-plus for those with co-morbidities; its earlier criteria were in line with NICE guidance.

It says it is increasing investment in community based services to prevent or manage weight problems earlier.

“The surgical option will be reserved for those patients with the highest BMIs, who are at most risk of the health consequences of morbid obesity and where the treatment has been shown to be the most cost effective,” a spokesperson said. However, despite this restriction, it expects the number of operations to increase this year.

Other specialist commissioning groups are still gathering information about demand and potential providers before adopting an SHA-wide approach. They say there are challenges in moving towards the NICE criteria. One is cost: bariatric surgery is comparatively expensive and will require follow-up and monitoring. If successful, it can offer significant savings - as patients lose weight they become less likely to develop chronic conditions (or conditions they do have may improve).

There is adequate evidence that bariatric surgery is cost effective for many patients, and is especially so for those with a higher BMI; however, those are future benefits whereas the surgery costs money now.

Second, not all areas have well developed bariatric surgery centres and developing these takes time. This was recognised by the original NICE guidelines, which saw the number of procedures slowly increasing. In the East of England, for example, many patients have to travel to London, even for outpatient appointments.

“There is no point in offering the service if we can’t find the providers,” says Carolyn Young, the commissioning group’s associate director of acute commissioning. “We want to ensure that before we move to wide criteria we have the capacity.”

But she stresses a whole pathway approach to obesity. As well as developing local surgery providers, services are needed to support people after surgery and also to ensure those who can lose weight without surgery do.

The 18 week target can also be a hurdle: patients may need time to consider bariatric treatment, slowing referral to treatment time. Mr Somers knows of one planned centre which was abandoned because it could not guarantee hitting targets.

But will all commissioning groups eventually fall into line with the NICE guidance? That is far from certain as finances get tighter and the nation gets fatter.

“The benefits of bariatric surgery are unequivocal and there should be more of it if we are not going to let obesity bankrupt the NHS over the next 10 years,” says Mr Somers. “If this was the position in cardiac surgery there would be an uproar.”

But, according to the Department of Health, there is no obligation on PCTs to fund in line with the NICE criteria.

Obesity surgery was originally covered by a technology appraisal which came out in 2002 and contained many of the same criteria included in the current clinical guidance. At that point PCTs were obliged to fund it - although relatively few procedures actually took place.

But once it moved into a clinical guideline, covering a more holistic approach to obesity, this obligation fell by the wayside, according to the DH - although PCTs are expected to fund clinical guidelines “as and when resources permit”.

NICE takes a different view and says PCTs are still bound by the funding direction. Its own monitoring suggests the number of bariatric procedures took off dramatically once the clinical guidelines were published.

But the numbers being treated are still tiny compared with the scale of the problem: in 2002 when NICE’s previous technology appraisal came out it said there were 1.2 million people who would fall within its criteria and that number was increasing by 5 per cent a year.

Even if only 2 per cent of people in that group were suitable and opted for surgery, that suggests there would now be around 30,000 people - some might already have accessed surgery - with 1,200 “new” cases each year.

More than 6,300 people were expected to fall into the BMI 50-plus group which NICE recommended for first line treatment with surgery in 2006.

Against that the number of procedures being done is tiny: less than 3,000 were carried out in 2007-08 and numbers may have grown to 4,000 last year.

And, as Mr Somers points out, the best chance of surgery for many of the morbidly obese comes with getting even fatter or developing a potentially life shortening co-morbidity.