NHS England rebuff GIRFT surgery recommendations

Getting It Right First Time, funded by the Department of Health and overseen by NHS Improvement, said clinical commissioning groups should change policies that restrict access to bariatric surgery by December where they are failing to comply with National Institute for Health and Care Excellence guidance.

The GIRFT report into general surgery, published last week, said there was a “clear mismatch” between levels of obesity and the provision of surgery as part of its work to reduce unwarranted variation and improve quality of care.

However, asked for a response by HSJ, NHS England challenged GIRFT’s recommendation, which would lead to some CCGs amending commissioning decisions.

NHS England said: “GIRFT has no role in specifying commissioning policy for CCGs.

“When it comes to bariatric surgery for adults, ultimately, these are legally decisions for local areas but informed by best evidence and national guidance where appropriate.

“NICE guidance is exactly that – guidance – and CCGs have a wider duty to consider the appropriate balance of spending within the limits of the funding at their disposal.”

The Five Year Forward View, published in 2014, said it made “little sense” for the NHS to spend more on bariatric surgery than prevention and lifestyle improvement programmes.

The NICE guidance says:

• Bariatric surgery is an option for people with a BMI of 40 or above if other non-surgical measures have failed and they are receiving intensive weight management services.
• Surgery should also be an option for people with a BMI of 35-40 if they have “other significant disease” that could be improved if they lost weight.
• Bariatric surgery is “the option of choice” for adults with a BMI of more than 50 when other interventions have failed.

The GIRFT report, written by general surgery clinical lead John Abercrombie, said the guidance was not being followed “in several regions” and there was a “clear mismatch”.

It showed East Midlands and the East of England were not fully compliant with any of the NICE criteria, while the North East, which has the highest rate of obesity, was only fully compliant with two.

In contrast, London and the South East were among the top three regions providing bariatric surgery despite having the lowest levels of obesity.

As one of its 20 recommendations, the GIRFT report said commissioners should ensure access to bariatric surgery complies with the NICE guidance, amending any “contrary referral” policies if required, by the end of the year.

The Royal College of Surgeons said it “strongly supports” the recommendation.

An RCS spokesman said: “Given the Department of Health and NHS Improvement’s backing for GIRFT, we hope that commissioners will take very seriously the recommendation to amend local policies that do not meet NICE guidelines by December.”

However, CCGs said GIRFT’s recommendation “may prove challenging”.

Julie Wood, chief executive of NHS Clinical Commissioners, said while the GIRFT approach to reducing unwarranted variation was “one that we and our members absolutely support”, implementing the recommendation could increase the financial burden on CCGs.

She said: “The report calls for the implementation of this recommendation by December this year, which may prove challenging given that contracts have already been agreed to cover this period, so some CCGs’ ability to make changes in this area will be restricted.

“Furthermore, they would need to consider the additional financial implications that implementing the recommendation may have, given the number of high priority competing demands on their already overstretched budgets.”

A spokeswoman for GIRFT said the team would “support CCGs to consider the evidence presented in the general surgery report to ensure appropriate access to and provision of bariatric surgery for patients in line with NICE guidance”.